H1N1 Behind Bars

What about cases in detainment and correctional facilities?

• James J. Augustine, MD
• 2009 Jun 25

A growing number of H1N1 cases are being reported in detainment and correctional facilities across the U.S., which prompts the question: How should EMS providers collaborate with these facilities and their staff?

Contagious diseases spread quickly in jails, prisons and other sites with crowded living quarters. Staff members are used to wearing gloves, are aware of the need to regularly clean detainee areas with disinfectants, and know that ill detainees should be isolated from the general population. The challenge is to equip these correctional facilities with the resources to protect against the respiratory spread of H1N1.

Prisons typically have an on-site medical staff, their own suppliers of medicines and vaccines, and often a mini-clinic. Prisons normally only use EMS for acute emergencies and transport to local hospitals.  

EMS care of inmates who are potentially infected with H1N1 should be based on standard local procedures for securing detainees and assuring law enforcement presence. Patient care should only be modified (if it hasn’t been already) to include a mask for the prisoner and personal protective equipment (PPE) for the EMS crew.

EMS leaders should participate in planning with fire, law enforcement, jail leaders and even the courts in preparing "the public safety cluster" for an infectious outbreak. 

These groups should all operate under similar protocols and procedures during the outbreak of an infectious disease. This includes a similar approach to PPE, preventive measures (e.g., vaccines) and cleanup procedures. The employees in the public safety cluster, typically employed by the same government entity, will be able to best serve the public if safety measures are consistent. It is also ideal for governments to stock jails and prisons with the same resources (i.e., N95 masks, gowns, gloves, goggles, bleach and other cleaning products) for consistency and as a cost-saving measure.

In the Event of an Outbreak
Both prisoners and facility staff may have early access to antiviral agents and/or vaccines to prevent outbreaks within the facility. They may also modify the ventilation systems to provide less re-circulated air. If there's a potential outbreak, prison staff may close the correctional facility or limit the number of outside visitors. EMS may even be asked to stay out of the facility and rendezvous at a point outside the incarceration area to pick up an ill prisoner. 

If an outbreak of H1N1 is confirmed, the first focus will be on the well being of public safety personnel. There should be consistent policies on use of PPE and the number of personnel who should come in contact with potentially infected individuals. When possible, only one public safety person should be within 6 feet of the patient. Each type of agency has what could be referred to as "high intensity" interactions, where multiple workers are needed to subdue, incarcerate, care for or manage the potentially infected person, and all public safety personnel exposed need to use a higher level of respiratory protection for those incidents.  In an outbreak, there should be an agreement as to how many personnel, and from which public safety group, the high intensity patient will interact with.

Information should also be provided on how vaccines, treatments or prophylaxis can protect the providers.   Also, the prison staff should make it clear that EMS has been activated to provide service to a detainee that either has or is at risk of having H1N1 so EMS can come prepared.

On arrival, prison staff should be wearing PPE similar to that of the EMS provider, and the prisoner should be wearing a mask. Any paperwork being used to transfer the prisoner should contain their history relating to the disease. And all usual security measures should be taken. If a law enforcement officer normally rides in the back of the ambulance to protect the EMS crew, this should continue.

Also, there will probably be special areas in the prison for fresh detainees who need to be tested for the flu and prisoners who are known to have the disease and are undergoing medical care. Intake questioning will probably include the individual's recent travel, recent medical history and any known exposure to the flu. 

Once a potentially infected patient has been moved into the next stage of the incarceration system, public safety personnel should thoroughly clean any exposed vehicles and equipment to protect the next person who has to use it. The exposure reporting system regarding the potentially ill prisoner should also be consistent between correctional facilities, law enforcement agents and EMS/fire personnel.

Conclusion
At present, there's no impending outbreak of H1N1 influenza in detainment and correctional facilities. But the increasing numbers of confirmed reported cases across the nation make it likely that the flu could affect correctional facility workers and detainees. Administrators will implement policies to reduce the possibility of the illness from entering detainee populations and to protect the staff. EMS should be aware of these policies and work with jail and prison staff so they're prepared for any outbreaks.

James J. Augustine, MD, is the assistant fire chief and medical director for D.C. Fire and EMS, the director of clinical operations at EMP Management, an associate professor in the department of emergency medicine at Wright State University, Ohio, and a JEMS editorial board member. Contact him at JAugustine@emp.com.  

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