CorrectCare

Flu Outbreak in Jail!
How We Stopped H1N1 in Its Tracks

by Vickie Freeman, MA, LMHC

On July 17 at 5:30 p.m., male inmate “A” was screened at the Collier County (FL) Jail. The normal intake screen of approximately 200 questions revealed little to raise concern. He had a temperature of 98.5 and denied any flu-like symptoms.

The global spread of the novel H1N1 virus, known colloquially as swine flu, has heightened the alert, particularly in correctional and detention facilities. The Collier County Sheriff’s Office and its health services provider, Prison Health Services, have attended several meetings hosted by the Florida Department of Health, Collier County, in preparation for a probable pandemic spread of the virus in the upcoming flu season. In an attempt to be proactive and control a possible outbreak, our facility during the previous few months developed a plan for a worst-case scenario including staffing issues. We also questioned new arrestees about travel to Mexico, then to other states and finally to nowhere in particular. The criteria to detect virus are now flu-like symptoms and a fever of 100 degrees or higher.

Since inmate “A” did not meet these criteria, he was placed in general population housing, an incoming housing area known as 5C. On the night of July 18 he was transferred to housing area 6B.

During the day of the 20th, he submitted a sick-call slip indicating he had a fever and a cold. He was interviewed by the nurse, who used the upper respiratory complaints nursing evaluation tool already in place. It was determined that he had a fever of 101.0 and a sore throat. A mask was placed on him and he was transferred from housing area 6B to one of four negative-pressure cells in the infirmary. A rapid test was performed to determine the strain of the influenza virus. He tested positive for the A strain.

The next phase of our plan kicked in. The medical staff asked the security staff to have the housing area from which the patient was moved cleaned with antibacterial cleaner, linen was exchanged and uniforms were changed out. Orders were received for a chest X-ray and labs. The physician ordered oral Tamiflu 75 mg twice a day. All inmates in housing areas 5C and 6B were cross-checked against the list of those identified with chronic illnesses or over the age of 65 and were assessed. None had symptoms, but each was treated preventively with oral Tamiflu 75 mg each day. Since the housing areas were all male, pregnancy risk was not an issue.

We notified the epidemiology department of the local health department and submitted a nasal swab to the state lab for determination of swine flu status. The health department evaluated the time line of events and determined that the patient became infectious on July 19, 24 hours before he voiced symptoms. The captain in charge of the jail notified his staff of the situation and all were reminded to use hand washing and good hygiene as preventive measures. All were advised that the case was not yet confirmed as H1N1. Unfortunately, the neighboring county reported the H1N1 death of a 51-year-old male who did not have a compromised immune system. We attempted, mostly successfully, to defuse any hype or panic, not only on the part of jail staff but also inmates and our liaisons in the justice system. This mainly involved normalizing the situation by explaining that we were prepared and were calmly dealing with it according to plan, and by providing commonsense information about preventing infection.

Checking the Spread
During medication pass on the morning of July 22, inmate “B” complained of flu-like symptoms. He was referred to the treatment clinic, where the upper respiratory complaints evaluation tool was used to detect symptoms that included cough and temperature of 100.0. A rapid test was performed, and he tested negative for the A strain. Since he also was located in the 6B housing area, and the validity of the rapid test was only 90% reliable, the medical staff made the decision to take precautions and isolate the patient. A mask was placed on the patient and he was transferred to a negative-pressure cell. He was given a preventive dose of oral Tamiflu 75 mg daily.

The precautions taken in this case proved highly valuable as the results of this patient’s X-ray revealed evidence of pneumonitis. Tamiflu frequency was increased to two times daily.

All of the activities described above became routine intervention for ruling out H1N1. In addition, a nursing assessment protocol for H1N1 was developed by our director of nursing and our medical director.

The following morning, on the 23rd, medication pass presented a third inmate who had a 102.5 temperature and a cough; the rapid test indicated that he was positive for the A strain of the influenza virus. This inmate was in the incoming housing area, 5C, but had been an overnight transfer from 6B. The inmate refused to wear the mask, claiming he could not breathe due to his stuffy nose. Security staff was then advised to don masks while encouraging the inmate to be placed in a third negative-pressure room. A culture was taken for state lab confirmation, and all preventive protocols noted above were initiated. The health department was contacted and a meeting with them took place almost immediately.

Epidemiology and health services officials from the county health department met with key jail administrative and health officials to go over the plans developed months earlier and determine how effective they would be under current circumstances. We decided to amend the plan to cease movement in and out of the two housing areas, 6B and 5C. Security changed its incoming transition housing to another place in the facility. The judiciary was notified that all court activities would continue over video monitor, as would attorney-client visitation. In addition, the medical staff would check temperatures and symptoms of those inmates remaining in those two housing areas twice daily beginning immediately.

The health department did not recommend a preventive dose of Tamiflu for those inmates, expressing concerns about tolerance build-up for future outbreaks. They did predict that the state lab confirmations for the submitted cultures had a 95% chance of proving positive for H1N1 since it was July and not the time of year when seasonal flu outbreaks take place. They also suggested not swabbing additional suspects for confirmation since a cluster group had already been identified.

During the initial check for symptoms in housing area 6B on July 23, three more inmates were identified with high temperatures and flu-like symptoms. Of all the patients isolated, we now encountered our first person with other medical issues that raised concern. A young male who had undergone multiple surgeries had a 104.0 degree temperature. Quick intervention resulted in preserving his health. It also became necessary to determine who would be housed together since we had six suspects and four negative-pressure cells. The director of nursing decided that the best clinical decision was to house together patients who were at the same stage in the disease process.

We were now hearing that the inmates in the closed housing areas were somewhat resistant to further isolation, and when we found an inmate with a qualifying temperature denying flu-like symptoms but voicing a dental problem, we took precautions and chose to isolate and treat the reported dental issue.

While all of this was happening, we also needed to deal with those inmates who were bonding out of those housing areas. When leaving those areas, they were masked through the exiting process and given literature and education regarding influenza. The fact sheets were available in English, Spanish and Creole.

The sheriff called for a briefing of the events and many chiefs and captains attended, along with PHS. He expressed his confidence we were doing all we could do to keep his men and women safe, as well as the inmate population.

On July 24, the news media reported that Florida Gulf Coast University had its first confirmed H1N1 case. The Collier County Health Department reported 51 confirmed cases, 11 in the previous week alone. We acknowledged that our findings were normal as we were part of the local community with similar medical issues. As of the 27th, no new suspects were found and we felt that we had identified the carrier and that the virus was somewhat contained. All were negative for fever and denied flu-like symptoms.

On the 28th, the health department reported that all three submitted cultures proved positive for the H1N1 virus. We are reminded to treat symptoms and not await results. This was a job well done by all. While the event was successfully managed and controlled, we came away knowing this could take place again next week, and we had a great practice run for a possible major fall outbreak.

— About the author: Vickie Freeman, MA, LMHC, is the health services administrator for the Collier County Jail, Naples, FL.

[This article first appeared in the Summer 2009 issue of CorrectCare.]