By Rachel D. Schwartz, MA, MS, PhD
Posted on January 4, 2010 –
Current pandemic influenza preparedness and response plans for corrections are largely based upon the H5N1 Avian Influenza outbreak, which has not materialized as a pandemic at this time. Many believe that the response to the ongoing pandemic of novel A H1N1 has been a relatively successful dry run for these plans, but for others, including the corrections community, the current response should raise a number of red flags regarding the actual state of preparedness in the corrections system.
The one-size-fits-all approach to pandemic planning that applies the same measures to very different types of outbreak, has already led to worldwide calls for more precise application of severity measures in determining the disease response levels of the WHO and CDC. In the case of the corrections response, specific difficulties have arisen as a result of implementing or trying to implement checklists and guidelines that were not prepared to deal specifically with a low-lethality disease like H1N1 and these recommendations are leaving corrections authorities with confusing and sometimes contradictory information.
Planning Assumptions
CDC checklists used or referred to by virtually all corrections pandemic planners are based on assumptions that don’t necessarily hold in the case of a disease like H1N1. For example:
a) The disease is lethal, requiring an all out response on all levels. b) There will be a grace period between an outbreak and its appearance in the US (the assumption with H5N1 was that it would come from Asia) which will allow for containment and tiered triggering opportunities. c) Because of its high lethality, the disease will likely lead to absentee rates of 40 and even 50% among corrections personnel.
Even when applied strictly to a highly lethal virus, these basic assumptions are problematic and raise serious questions such as, where would the resources for an all out response come from? How would they be paid for? How would they be distributed? How effective would containment efforts be, especially in light of the ease of transmission through global transportation and travel? And how would facilities operate with such severe absenteeism, especially given the new responsibilities pandemic plans required of them?
When applied to the low-lethality H1N1 outbreak, these assumptions are not only problematic, but inappropriate. Thus, unlike H5N1, H1N1 does not call for significant levels of isolation, quarantine, and PPE usage. Yet correctional institutions operate using plans that require such measure be taken, or at least seriously considered. Facilities with only a few mild cases, like Rikers Island, even weighed the possibility of partial or even full closure as demanded by Norman Seabrook, president of the Correction officers’ Benevolent Association. As a result of complaints by Seabrook, the correction officers’ union, and others, new precautions including sanitizing areas where sick prisoners were held, screening all inmates who leave the island for court appearances, and deployment of medical workers at the jail complex to consult with staff and screen prisoners have been implemented. The additional cost and personnel involved is stressful and costly for corrections personnel as well as the system itself.
Moreover, flu plans written for H5N1 assumed a window of time to prepare and to limit or contain spread but were inapplicable to H1N1 – as seen in the Rikers outbreak and elsewhere. Indeed, the disease was already well-established in the US by the time it was recognized, making border closures and other efforts at containment virtually useless, and leaving corrections institutions to deal directly with a fait accompli.
Finally, despite anger and anxiety among corrections personnel working where H1N1 has occurred, the disease has not caused significant absenteeism. Perhaps this is because it is becoming clear that the disease is not as lethal as they had been led to expect by their training for the H5N1 response. Indeed, the strongest reactions to the outbreak were in the first weeks of its appearance, when it was unclear just how serious a disease it was. If an alternative to the high-lethality response plan had existed (as well as a better understanding of the range of influenza severity), much of the fear and tension could have been avoided.
The lack of such an alternative plan (really a somewhat stepped down version of the high-lethality plan) has been the cause of much confusion and in some cases overreaction, leading to calls for closing international borders and limiting travel, locking down or closing unaffected schools and other institutions, and sending so many influenza tests that labs are overwhelmed with unnecessary tests for which neither personnel nor funding is available. Even though these steps have not been taken (at least not broadly), uncertainty and insufficient guidance have left responders in a difficult position.
New CDC Guidelines
Aware of the gaps between the reality of the H1N1 situation and the H5N1 plans, the CDC issued new guidelines on May 24, 2009, aimed at tailoring a response to the H1N1 outbreak for correctional and detention facilities. But while some of these guidelines offer solid clinical advice, many are impractical, contradictory, or still appear to be based on the assumptions of H5N1 plans.
Thus, for example, the new guidelines recommend that during an H1N1 outbreak, corrections facilities implement social distancing strategies that are clearly not feasible given the current overcrowding and lack of personnel and resources in most facilities. Consider the staffing implications of the recommendation for dividing facilities into two areas, one with sick or exposed inmates, the other with well inmates. This would require two entirely separate sets of staff, and many more resources at a time when, according to the guidelines themselves, there would be less staff and fewer resources. Moreover, it’s questionable if social distancing is so crucial with a virus described by interim CDC head Besser, as not much worse than a bad case of the flu.
Furthermore, while guidelines urging cooperation with local public health agencies (LPHAs) make excellent sense, they do not take into account the fact that LPHAs usually lack resources to provide antivirals to corrections personnel either for treatment or prophylaxis, as the guidelines suggest. Indeed, with H1N1 in its current form, these are probably not needed.
Finally, as Dean Rieger MD MPH notes, by changing the definition of what a suspect case is from someone with fever, two of the following three items – a cough, runny or stuffy nose, and a sore throat – to someone with symptoms of influenza-like-illness (ILI) – fever and either cough or sore throat – the new CDC guidelines overly broaden the pool of possible flu victims to the point that nearly anyone with a fever could trigger a panicked pandemic response, including social distancing, segregation of inmates, separation of staff, etc. Thus an attempt to improve sensitivity to disease would lead to a huge number of false positives that would strain an already strained system.
The Second Wave
When H5N1 failed to materialize as a serious threat because of its inability to move easily between humans, it was viewed as a dodged bullet. H1N1 is currently also being seen by many in the same light. However, given that H5N1 continues to spread, especially in Indonesia and Egypt, it is too early to write it off; especially as it now exists side by side with the highly contagious, though low-lethality H1N1, in situations that might be conducive to reassortment. Moreover, even if H5N1 is out of the picture next flu season, it is likely that H1N1 will return, perhaps having mutated to a more lethal disease much as occurred with the 1918-1919 Spanish Influenza. Therefore, we cannot afford to congratulate ourselves on a successful escape from serious pandemic effects. Indeed, it is crucial that corrections facilities train and prepare for measures that deal with the range of mild to severe disease, possibly employing a tiered response system. Moreover, the plans must be improved according to realistic, appropriate and operational guidelines.
Such planning can only occur if, as the CDC notes, there is good collaboration between stakeholders. In this case, it is crucial that planning be carried out not only by planning professionals, but also by those who truly understand what can be operationalized and what cannot; what is realistic, and what fails to take into account the facts on the ground in correctional facilities. Thus clinical and custodial personnel, as well as local and federal public health personnel and experts in the field of pandemic response must work together to develop plans that are appropriate and specific to different disasters and to the unique needs of the corrections community.
Short Bio:
Rachel D. Schwartz, MA, MS, PhD, is an Assistant Professor at the Institute for Biosecurity and Disaster Preparedness, Saint Louis University School of Public Health. She teaches in the online MS/PhD in Biosecurity and Disaster Preparedness, conducts research in the field of pandemic preparedness, preparedness paralysis, and absenteeism with a special interest in corrections and vulnerable populations.
Rachel D. Schwartz, MS, PhD
3545 Lafayette, Suite 300
Salus Center
St. Louis, MO 63104
Rschwar7@slu.edu 314 977-3247
