An Appropriate Response?

By Anne Spaulding, MD, MPH, CCHP, and Madhura Adiga

Posted on January 4, 2010 –

The article by Dr. Schwartz merits a strong response when she asks whether current CDC guidelines for the novel H1N1 influenza virus trigger an unnecessarily “panicked pandemic response.” Dr. Schwartz makes several points:

• The current CDC checklists for pandemic influenza require an “all out response on all levels” which is inappropriate for the current outbreak of mild influenza. (See www.flu.gov/ professional/business/ correctionchecklist.html)
• Local public health authorities may not be able to help correctional facilities in the face of a true emergency.
• Containment strategies are not feasible given the current overcrowding and lack of personnel and resources in most facilities.

In fact, the interagency U.S. government website for influenza (www.flu.gov) tailors recommendations based on the severity of illness. The World Health Organization (WHO) has assigned the current situation as Phase 6, the highest pandemic phase, meaning that there are human-to-human outbreaks in more than one WHO region. Having a high phase designation does not mean that international health leaders are misgauging the severity of illness. The phase designations can refer to any influenza outbreak regardless of its origin or severity; it only reflects the outbreak’s geography. As health care leaders, we can recommend a level of response fitting for the severity of disease, in order to keep inmates and our coworkers safe.

While most cases of H1N1 influenza are mild, the virus still can kill. As this commentary goes to press, five thousand persons have died worldwide. The toll has been great in persons in their 30’s and younger. For health care leaders in correctional institutions where the mean age is in the 30’s, we should be concerned, especially since inmates live in such close proximity to one another. Ninety percent of persons hospitalized are less than 65 years old. The average age of persons admitted to an ICU is 29 years of age. Equally striking is that the average age of the persons who died was 26 years of age. Thirty-five to forty-five percent of persons who have been hospitalized had no underlying chronic medical condition.

Influenza is the leading cause of death from a vaccine preventable infection. Let’s get in line to procure H1N1 vaccine for our patients who need it, especially pregnant inmates and those with severe cardiac, pulmonary, immunodeficiency or neurodegenerative disease. All persons in the recommended target groups should receive the vaccine unless they have had infection proven to be H1N1 by real time reverse transcriptase PCR. As correctional health care workers, we also will need to roll up our own sleeves for the vaccine.

Dr. Schwartz says that local public health agencies often lack resources in time of need. The corrections checklist stresses forming relationships before crisis occurs. Such an approach worked when influenza struck the Cumberland (ME) County Jail. In their presentation at this year’s National Conference on Correctional Health Care, “From the Shuffle to the Tango When H1N1 Waltzed In,” presenters Meyer, North and Walsh described how they were able to handle H1N1 adequately, precisely because they had a strong relationship with their health department. Appropriate antiviral medications were obtained. Infected inmate-patients were sequestered in an empty housing unit. They were preparing for the :tango (H5N1), but were able to respond to the “waltz,”(H1N1) because relationships were in place.

Adequate planning saves lives by preparing us for a variety of crises. Use the present headlines as a catalyst to call together a pandemic planning group if your institution has yet to form an outbreak plan. Establish a working relationship with your local health department so that when an outbreak of influenza-like illness appears, you might receive adequate support to determine whether infections are from oseltamivir susceptible H1N1 or a resistant strain of another influenza virus-rapid antigen tests have lacked sensitivity. Also, go to the Federal Bureau of Prison Web site and read recently updated guidance on Surveillance:

www.bop.gov/news/PDFs/pan_flu_ module_1.pdf

Treatment:
ww.bop.gov/news/PDFs/pan_flu_ module_2.pdf

Health Care Delivery:
www.bop.gov/news/PDFs/pan_flu_ module_3.pdf

Yes, an ounce of prevention is worth a pound of cure.