Interim Guidance for Correctional and Detention Facilities on Novel Influenza A (H1N1) Virus

May 24, 2009 6:00 PM ET

This document provides interim guidance specific for correctional facilities during the outbreak of novel influenza A (H1N1) virus to ensure continuation of essential public services and protection of the health and safety of inmates, staff and visitors. Recommendations may need to be revised as more information becomes available.

Background

Correctional institutions pose special risks and considerations due to the nature of their unique environment. Inmates are in mandatory custody and options are limited for isolation and removal of ill persons from the environment.  The workforce must be maintained and options are limited for work alternatives (e.g., work from home, reduced or alternate schedules, etc.). In addition, many inmates and workforce may have medical conditions that increase their risk of influenza-related complications. The focus of this guidance is on general preventive measures for institutions, risk reduction of introduction of the virus into institutions, rapid detection of persons with novel influenza A (H1N1) infections, and management and isolation of identified cases.  In this document, institution refers to staff, inmates, and visitors. Correctional facilities should contact and collaborate with their state, local, tribal and territorial health departments for more specific guidance.

Symptoms of Influenza-like Illness and Possible Novel Influenza A (H1N1)

Symptoms of influenza-like-illness (ILI) include fever and either cough or sore throat. In addition, illness may be accompanied by other symptoms including headache, tiredness, runny or stuffy nose, body aches, diarrhea, and vomiting. Like seasonal flu, novel influenza A (H1N1) infection in humans can vary in severity from mild to severe.  When severe, pneumonia, respiratory failure and even death are possible.

General Prevention Recommendations for the Facility

• Encourage all persons within the facility to cover their cough or sneeze with a tissue. Throw all tissue in the trash after use. Maintain good hand hygiene by washing with soap and water, or using an alcohol-based hand sanitizer, especially after coughing or sneezing.  Avoid touching eyes, nose and mouth without cleaning hands. See Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Novel Influenza A (H1N1) Virus Infection in a Healthcare Setting.        
• Make the means for appropriate hand cleansing readily available within the facility, including intake areas where inmates are booked and processed, visitor entries and exits, visitation rooms, common areas, and staff-restricted areas, in addition to lavatories and food preparation and dining areas. The means for hand cleansing are ideally running water, soap, and hand drying machines or paper towels and waste baskets; alternatively, except in lavatories and food preparation areas, alcohol-based hand sanitizers may be used.
• Clean all common areas within the facility routinely and immediately, when visibly soiled, with the cleaning agents normally used in these areas. Eating utensils should be washed either in a dishwasher or by hand with water and soap.  Cups and utensils should not be shared until after washing.
• Respiratory hygiene/cough etiquette should be implemented beginning at the first point of contact with a potentially infected person to prevent the transmission of all respiratory tract infections in the correctional settings. 

Reduction of Risk of Introduction into the Institution

• Potential visitors should be informed that anyone who had an influenza-like illness (ILI) in the 7 days prior or who still has symptoms of ILI 7 days after illness began may not enter the facility. When possible, facilities should use their usual communication channels to inform potential visitors of these rules before they travel to the facility. For example, facilities can ask inmates to inform their family members and visitors. In addition, visitors should be informed via signage (e.g., visuals, posters) in the visiting areas. See Respiratory Hygiene/Cough Etiquette in Healthcare Settings.
• Exclude visitors who had ILI in the 7 days prior or who still have symptoms of ILI 7 days after illness began.
• Staff with ILI should stay home (or be sent home if they develop symptoms while at the facility), and remain at home for 7 days or until 24 hours after symptoms resolve, whichever is longer.
• If there is ILI in the facility, cancel internal group gatherings and stagger group meals and other activities to provide more personal space between individuals. Consider temporarily suspending visitation or modifying visitation programs, when appropriate.

Rapid Detection of Cases

• Instruct inmates and staff to report symptoms of ILI to the facility health care professional at the first sign of illness.
• Evaluate incoming inmates and isolate if they display symptoms of ILI. See Interim Guidance for Clinicians on Identifying and Caring for Patients with Swine-origin Influenza A (H1N1) Virus Infection.
• Consider daily temperature checks in units where ILI cases are identified.   
• Testing of some persons with ILI should be done to determine what viruses are circulating at the institution.

Management and Isolation of Suspect and Confirmed Cases

• Staff caring for sick inmates should follow CDC guidance for the care of sick persons.
• Refer toCDC interim guidance facemask and respirator use to reduce novel influenza A (H1N1) Virus transmission.
• Influenza antiviral chemoprophylaxis may be given to inmates and health care personnel in accordance with current recommendations to reduce spread.
• Actively monitor the number, severity, and location of cases of ILI.
• Separate inmates with ILI from others by placing them in individual cells when possible.  Consider separating cell mates of sick inmates for 48 hours for observation.
• Provide care of inmates with ILI, including scheduled temperature checks and access to increased fluids, and antiviral treatment when indicated. Also provide tissue, a plastic bag for the proper disposal of used tissues, and alcohol-based hand sanitizers.
• Restrict movements of inmates with ILI within the facility and restrict inmates from leaving, transferring from or to another facility during the 7 days after onset of symptoms or until 24 hours after symptoms resolve, whichever is longer, unless necessary for medical care, infection control, or lack of isolation space.
• If multiple inmates become ill with novel influenza A (H1N1), establish a designated area of the institution specifically for sick persons.  Designate staff to care for these individuals only, and do not have these inmates circulating in other parts of the institution. Limit movement of designated staff between different parts of the institution to decrease the risk of staff spreading influenza to other parts of the facility. See Using Antiviral Medications to Control Influenza Outbreaks in Institutions.
• Linens, eating utensils, and dishes belonging to those who are sick do not need to be cleaned separately, but they should not be shared without thorough washing. Linens (such as bed sheets and towels) should be washed by using laundry soap and tumbled dry on a hot setting. Individuals should avoid “hugging” laundry before washing it to prevent contaminating themselves. Individuals should wash their hands with soap and water or alcohol-based hand sanitizer immediately after handling dirty laundry.
• Assess and treat as appropriate soon-to-be released inmates with ILI or other flu symptoms and make direct linkages to community resources to ensure proper isolation and access to medical care. 
• The facility health care providers should identify and address the special health needs of persons at high risk for complications following infection with novel influenza A (H1N1) virus. Persons at high risk for complications from novel H1N1 infection may be similar to those who are at high risk for seasonal influenza complications and include the following: persons age 65 years and older, pregnant women, persons of any age with chronic medical conditions (such as asthma, diabetes, or heart disease), and persons who are immunocompromised (for example, taking immunosuppressive medications or infected with HIV).  Information on the aforementioned high risk populations can be found at the following links.
  See Pregnant Women and Novel Influenza A (H1N1) Considerations for Clinicians
  See H1N1 Flu and Patients With Cardiovascular Disease (Heart Disease and Stroke)
  See Interim Guidance—HIV-Infected Adults and Adolescents: Considerations for Clinicians Regarding Swine-Origin Influenza A (H1N1) Virus.

Protection of the Workforce

• Strict adherence to general hygiene practices should be followed. See Interim Guidance for Infection Control for Care of Patients with Confirmed or Suspected Novel Influenza A (H1N1) Virus Infection in a Healthcare Setting.
• Follow current vaccination recommendations and offer the current season’s influenza vaccine to unvaccinated staff and health care personnel. See Infection Control Guidance for the Prevention and Control of Influenza in Acute-Care Facilities.
• Influenza antiviral chemoprophylaxis may also be given to staff working directly with sick inmates in accordance with current recommendations to reduce risk and spread. See Interim Antiviral Guidance for 2008-09 and Antiviral Chemoprophylaxis for Novel (H1N1) Influenza.
• Information on mask and respirator use is available at Interim Recommendations for Facemask and Respirator Use to Reduce Novel Influenza A (H1N1) Virus Transmission.

Other Considerations for Non-English Speaking Detainees

Educational materials and information should be provided to inmates and visitors in a way that can be understood by non-English speakers.

• When evaluating and treating persons with symptoms of ILI provide a translator, if possible.
• Spanish-language materials are available at: CDC H1N1 Flu web site in Spanish.
• Materials and information in other languages are available at: CDC web sites in other languages and Illinois Department of Public Health H1N1 Flu website in other languages.

Appropriate measures must be taken to ensure that such individuals housed temporarily in detention centers receive adequate medical evaluation and treatment at the first signs of ILI symptoms. If adequate medical care is not available, accommodations should be made for safe transfer of the individual to another facility.