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OCTOBER/NOVEMBER 2006
Main Article:
Pandemic Flu Preparedness and Response in Corrections Facilities
Rachel D. Schwartz, PhD Institute for Biosecurity Saint Louis University School of Public Health Disclosures: Research Grant: Roche Pharmaceuticals Introduction In 2003, one person in China and three in neighboring Vietnam became infected with Avian Influenza (H5N1). All died. Last year, 95 human cases with 41 deaths from Avian influenza were reported to the World Health Organization (WHO), and already this year, there have been 94 cases with 63 deaths in Africa and Asia - including Turkey and Azerbaijan. Although the total number of cases has been low, and transmission has been primarily from animal to human, the high mortality rate and lack of effective treatments or vaccines for Avian influenza (H5N1) have fanned concerns that the virus could mutate to become transmittable between humans, and wreak the kind of worldwide devastation caused by the 1918-1919 Spanish Influenza pandemic - a global outbreak that caused approximately 50 million deaths worldwide, and created socio-economic and political havoc. The historical pattern of pandemic influenza cycling suggests that it is not a matter of if, but when, the next pandemic will emerge and some experts worry that H5N1 or a similar virus will be responsible. The potential threat of a global influenza pandemic has triggered efforts to increase outbreak surveillance, preparedness and response planning, as well as the research and development of therapeutic interventions. In the US many state and local institutions, hospitals, schools, utilities, corporations, communities and families are receiving support and tailored information to assist them in developing procedures to prepare for widespread influenza yet, to date, the unique issues of correctional institutions have largely been ignored. Currently, over 9 million people are held in penal institutions throughout the world, with over 2 million in the US.1 Rather than being insular and isolated, the populations of both jails and prisons are dynamic with inmates frequently entering and leaving these facilities. The fluidity of movement of individuals between correctional facilities and their communities can have serious public health implications were pandemic influenza to strike. Within the confined facilities of a jail or prison it is not difficult to image how the entry of even a single person, inmate or staff, incubating highly infectious pandemic influenza could spark a devastating outbreak - akin to the lethal waves of influenza that spread among the barracks of soldiers in the early twentieth century. With so much at stake, and so many variations in types of correctional facilities, flexibility in planning for pandemic influenza is critical as each jail and prison must adapt responses to their own specific circumstances, while taking advantage of the strategies that apply to all. In this paper we consider some of the unique issues faced by correctional facilities in their efforts to plan for pandemic preparedness and response. We examine the physical and social make-up of the inmate population; access to medications, including antivirals and vaccines; surveillance and reporting; access to hospitals and medical facilities; infection control and containment; and staff absenteeism. The incarcerated population at risk Many incarcerated persons may be at relatively higher risk for influenza infection. According to the American College of Physicians (2001), the incarcerated population is disproportionately made up of members of vulnerable and underserved groups and is primarily male, minority, and younger adult but with a growing number of elderly inmates. Many inmates suffer from immunological and infectious diseases including HIV/AIDS, Hepatitis C Virus infection, tuberculosis and others.2 Drug resistance is a growing problem (e.g. multi-drug resistant TB, methicillin-resistant Staphylococcus aureus), as are mental illness and a lack of consistent health care prior to entering and upon release from the corrections system.3 Scientific and historical evidence indicates that infectious disease outbreaks in such closed environments tend to be "explosive in nature, with high attack rates as well as significant morbidity and mortality 4," and that prison overcrowding - a serious problem in many facilities - is a major contributor to disease spread.5 If, as most pandemic planners now posit, 30% of the general population is likely to contract pandemic influenza, it may be further assumed that incarcerated populations will suffer at least the same rate of infection or higher. Surveillance and reporting Successful infectious disease response is predicated upon effective surveillance and reporting. In the event of a rapidly spreading airborne viral infection, such as influenza, accurate reporting of cases is essential to the mounting of appropriate public health responses. How well institutions such as correctional facilities, nursing homes, businesses, hospitals and schools will perform is unclear. There is particular concern that some jails and prisons are ill-prepared to quickly recognize and report an emerging influenza outbreak. In its July 2002 report, the National Institute of Justice and the National Commission on Correctional Health Care (NCCHC) note that of 41 state departments of corrections surveyed, "less than half.reported having data on the number of inmates with chronic diseases such as diabetes, asthma or hypertension." Furthermore, "few systems can measure the prevalence of communicable disease." - information crucial in tracking the progress of disease and devising treatment strategies. To meet this challenge prisons and jails must develop and enhance their surveillance capabilities. Essential elements include the education of medical personnel in disease recognition and reporting. Procedures detailing who within the correctional system should be contacted regarding suspected cases (and how this communication should be made) need to be formulated. Further, it should be made clear who in the system is responsible for alerting local and state authorities of suspected or confirmed cases. Access to hospital services and care Most pandemic influenza models assume that hospitals and other health care facilities will be ill-equipped to respond to a pandemic. Within a short time of the onset of the disease in the population, such centers will be overwhelmed by the influx of patients and by the high absentee levels among staff. In fact, Hick, Daniel, and O'Laughlin note that despite significant medical advances since the last pandemic (1968-69), the decrease in inpatient beds, increased emergency department crowding, and contraction of intensive care unit bed capacity, staff and overall resources may lead to a situation in which "many patients of a modern pandemic may receive medical care similar to that provided to patients during the 1918 pandemic." 6,7 At a minimum, hospitals will be forced to institute altered standards of care, limiting or halting elective procedures, and resorting to triage systems in which treatment is given only to those most likely to survive.6 This will be especially important when shortages of ventilators and other acute care supplies develop, a likely scenario given that these are often required in the treatment of pandemic influenza cases. These strains on the health care infrastructure will have implications for correctional facilities. Under such conditions, hospitals may be unlikely to accept patients from corrections facilities for treatment. Even if hospital transfer is an option, shortages of custody staff stretched thin by increased inmate hospitalization and illness among their own ranks would make it extremely difficult to provide the security needed to make patient transfers possible. An additional concern is the possibility that in the event of pandemic influenza, inmates will be considered a relatively low priority in so far as allocation of preventative and therapeutic interventions that may be in short supply. Antivirals and vaccines may be rationed, and prisoners, despite their heightened risk for infection, are at risk for being passed over. Unfortunately, there is precedent for such discrimination: in light of a shortage of seasonal influenza vaccine for the general population, the governor of one state ordered vaccine supplies used in correctional facilities to be distributed instead to the general population, over the objections of prison authorities. In order to help ensure that vaccine and medication supplies are available to inmate-patients, correctional authorities need to partner with government officials and explain to the relevant authorities (and the general populace) the individual and public health justification for providing prisoners access to these medications and vaccines. Treatment and containment strategies It is probable that in the setting of an overwhelmed health care system, most corrections authorities will need to assume care for sick inmates within their facilities. Each facility must prepare and exercise a plan that provides for the housing and care of sick inmates far beyond the present capacity of their infirmaries. The plan will have to take into account the possibility that quarantine may be necessary, requiring dedicated facilities and training in implementation for staff. Staff (including health care and custody) and inmates will also need training in basic hygiene, infection-containment and control measures. The use of personal protective equipment (PPE) must be enforced among staff and inmates (see idcr-o-gram). Locking down correctional facilities for security or isolation/quarantine over a long stretch may not be necessary during a pandemic but in the case of sporadic outbreaks it is possible public health authorities will restrict movement into and out of correctional facilities. For example, health care workers in China and Canada were confined to their hospitals during the SARS outbreak. Some experts have also suggested that under such conditions, authorities may wish to retain all inmates until they are deemed healthy, regardless of release dates. It may also be necessary to institute mandatory quarantine of new inmates before they are introduced into the general population, or are moved between facilities. Absenteeism Recent research into pandemic response has led to estimates of 40% absenteeism as standard for populations who grow ill or stay home to care for others or protect themselves. In preparation, it will be crucial to develop some redundancy in staff (ideally at least 3 deep) so that if the warden is unavailable, a trained designee will be able to step in and carry out the warden's responsibilities effectively. In the case of health care workers, this will require cross-training. Such plans are more likely to be successfully implemented during a time of need if they are outlined and explained to the staff ahead in advance. Clearly, some absenteeism is unavoidable, given that staff will fall ill, as will family members who require care. The goal must therefore be to minimize absenteeism among the well, in part, by providing a safe working environment with the availability of PPE, and to encourage the return of those who have recovered from the disease (i.e. enforce 100% vaccine coverage to staff). Annual seasonal influenza vaccination drives among employees will help prepare staff for vaccination in the case of a pandemic, if a vaccine become available. To further augment staff numbers, corrections administrators should also consider contacting retirees and reliable volunteers and training them to step in when they are needed. Conclusions During an influenza pandemic, inmates may be particularly vulnerable to infection due to the close quarters in which most live as well as the relatively high prevalence of co-morbid health conditions. While intensive efforts to prevent and contain an outbreak in prisons and jails can be justified as good public health policy, popular opinion during the chaos of a pandemic may threaten this logic and lead to rationing of scarce resources away from correctional settings. Correctional systems of all sizes need to consider their current state of preparedness for pandemic influenza and other similar catastrophes. It is difficult to fully prepare for the worst and few, if any, correctional facilities can adequately plan to meet the challenges of a pandemic of influenza without substantial coordination with local health authorities. However, by outlining some of the problems correctional facilities will likely face during an outbreak we hope to help administrators of jails and prisons to begin to consider how they would function during such a catastrophe. The specter of pandemic influenza is one that is almost too horrific to imagine; however, now, on the cusp of winter, is the perfect time for correctional facility health and custody leaders to assess how well-prepared the facility is to deal with such an outbreak - remembering, it is not a question of if, but when. References: 1Walmsley R. World Prison Population List, International Centre for Prison Studies, 2005. Available at: http://www.csa.nsw.gov.au/ downloads/world-prison-population-list-2005.pdf 2 American College of Physicians Public Policy Paper. Correctional Medicine. 2001;2. 3 King's College London: International Centre for Prison Studies. Guidance Note 10: Improving Prison Health Care. 2004. 4 Awofeso N, Rawlinson WD. Influenza control in Australian prison settings. International Journal of Prison Health. 2005;1(1);31-38. 5 Walmsley R. World Prison Population List, International Centre for Prison Studies, 2005. http://www.csa.nsw.gov.au/downloads/world-prison-population-list-2005.pdf. 6Hick JL, O'Laughlin DT, Concept of Operations for Triage of Mechanical Ventilation in an Epidemic. Journal of Emergency Medicine.2006;13(2):223-29. 7 Jürgens R, et al. From evidence to commitment to action: Implementing HIV prevention measures in prisons in Ukraine. Abstract no. TUAX103. 8 Wysocki B, Lueck S. Just-in-time inventories make US vulnerable in a pandemic. Wall Street Journal. January 10, 2006;A1, A7 Joint United Nations Program on HIV/AIDS. HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings: A Framework for an Effective National Response. United Nations. 2006. Available at www.unodc.org/pdf/HIV-AIDS_prisons_July06.pdf. |
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