by David M. Reutter

For hundreds of years the cramped, overcrowded and often filthy confines of dungeons, prisons, jails and other places of imprisonment have served as incubators for infectious diseases, which have killed more prisoners than any other single factor. Thus, the recent outbreak of H1N1 virus, commonly known as “swine flu,” had government officials very, very worried.

Their concerns were heightened on June 11, 2009, the day when the World Health Organization declared that a global pandemic of swine flu was underway. While the mainstream media has focused on the threat that H1N1 poses to the general public, health officials are also concerned about the risk of a major outbreak in prisons. Last May, the Centers for Disease Control (CDC) created interim guidelines to address the problem of swine flu in correctional settings.

Although prisons and jails by their nature are isolated and contained, infectious diseases spread quickly once they enter the prisoner population. “It’s a perfect breeding ground,” said Sheriff James DiPaola of Middlesex, Massachusetts.

As noted by the CDC, “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.”

What worries officials is that most prisons and jails have three shift changes a day, during which dozens of people move in and out of the facility. Employees can transmit diseases to prisoners or can carry infections from the prison and expose their family members. Prison officials hope to prevent such cross-contamination with swine flu. “We don’t want to be bringing this home to our kids, which is what happened with MRSA [staph infection],” said Steve Kenneway, president of the Massachusetts Correction Officers Federated Union.

Thus far, cases of swine flu in U.S. prisons and jails have been widespread but there have been few deaths. The low fatality rate is attributed to the characteristics of the virus and the type of people who are most susceptible to infection.

Swine Flu 101

H1N1 first appeared in Mexico in April 2009; it became known as swine flu after laboratory tests indicated that some of the virus’ genes were similar to influenza strains that normally occur in pigs. Further research revealed that H1N1 is very different from viruses in North American swine. In what scientists call a “quadruple reassortant” virus, H1N1 has two genes that normally circulate in pigs in Europe and Asia, as well as bird (avian) genes and human genes.

With a 42% infection rate after contact with someone who has swine flu, the virus is easily transmitted person-to-person through coughing or sneezing. According to the CDC, those who are “infected with seasonal and 2009 H1N1 flu shed virus and may be able to infect others from 1 day before getting sick to 5 to 7 days after.”

Swine flu can be spread by touching a surface or other object where the virus is present and then touching your mouth or nose. “Studies have shown that influenza virus can survive on environmental surfaces and can infect a person for 2 to 8 hours after being deposited on the surface,” the CDC warns. H1N1 cannot be transmitted by eating pork or pork products.

Unlike seasonal flu which occurs annually, persons age 65 and older are the least likely to be infected with swine flu. Those at higher risk of contracting H1N1 include people who are pregnant, younger than 25, or who have medical complications such as asthma, diabetes, suppressed immune systems, heart disease, kidney disease and neuromuscular disorders. Once a person is infected with swine flu and recovers, their body builds resistance to that strain of the virus, which should prevent re-infection.

Prisoners come into contact with the same surfaces, fixtures and objects that are touched by hundreds of other prisoners on a daily basis – such as door handles or salt shakers in the dining hall. That situation, and close proximity to other people who may cough or sneeze, can result in swine flu outbreaks.

A few simple steps can be taken to protect oneself. Ask prison medical staff to provide face masks if they do not do so already. Wash your hands for at least 20 seconds with soap and water often, especially after contact with common surfaces.

Try not to touch your eyes, nose or mouth; germs are easily spread that way. Avoid close contact with people who are sick or who exhibit flu-like symptoms. Do not share cups, dishes or eating utensils until they have been washed. If you become infected with H1N1, the CDC recommends that you avoid contact with others for at least 24 hours after your fever is gone. Cover your mouth when you cough or sneeze.

Newton E. Kendig, the medical director for the U.S. Bureau of Prisons, described a creative way to curb the spread of swine flu. “Realizing that nearly all the inmates touch a single door knob when they enter the dining hall,” he said, “one warden paid an inmate to hold the door open.”

The signs and symptoms of H1N1 include fever, a non-productive cough, severe body aches, a stuffy or runny nose, headache, chills, chest discomfort and fatigue. Some people may experience vomiting or diarrhea. The simple hygiene precautions described above should be followed to reduce the risk of infection.

As Goes California ...

As of late December 2009, forty-nine states reported some level of swine flu activity, mostly sporadic or local out-breaks. That was a major improvement over the previous two months, when H1N1 infections and fatalities peaked and forty-eight states reported “widespread” cases of the virus.

Nationwide, during the worst period of the outbreak from October to November, there were 3,280 to 4,985 hospitalizations and more than 170 deaths per week over a 4-week period. According to the CDC, an estimated 34 to 67 million cases of H1N1 occurred in the U.S. between April and November 14, 2009, and there were an estimated 7,070 to 13,930 swine flu-related deaths during that period. Those figures are much higher than confirmed cases though.

“Our best estimate right now is that the fatality [rate for H1N1] is likely a little bit higher than seasonal influenza, but not necessarily substantially higher,” said Dr. Anne Schuchat, director of the CDC’s National Center for Immunization and Respiratory Diseases.

Swine flu outbreaks have been reported in prisons and jails across the country. California, with the nation’s largest state prison system, is not surprisingly the leader in confirmed cases among prisoners. Statewide, as of November 2009 there were 767 cases of H1N1 and three swine flu-related deaths in California prisons.

Last May, state officials canceled visitation and banned non-essential workers at all 33 adult prisons and six juvenile facilities in California after a prisoner at Centinela State Prison was diagnosed with swine flu. Although visits were sus-pended for about 10 days, prison staff continued to go in and out of the facilities and return to their homes in the commu-nity, largely defeating the purpose of the no-visit restriction.

Thirty-five prisoners exhibited swine flu symptoms at San Quentin in early July 2009 and the prison was quarantined. The facility stopped accepting incoming transfers, and about 2,100 prisoners were restricted to their cells.

Over 1,240 prisoners at the Men’s Central Jail in Orange County were placed on lockdown in July after five cases of H1N1 were reported. While prisoners were confined to their cells during the quarantine, the jail continued to accept new arrivals who were then subject to the lockdown.

That same month there were 20 confirmed cases of swine flu at the Los Angeles County jail; consequently, 190 prisoners were isolated to prevent spreading the infection. Another 20 prisoners were treated for probable H1N1 at the jail in San Joaquin County, and the Sacramento County jail reported one confirmed case of swine flu.

More than 1,000 prisoners were quarantined in San Diego County’s jail system in July. Fifty-six prisoners and 11 employees exhibited flu-like symptoms; the employees were sent home while the prisoners were transferred to Donovan State Prison.

A precautionary quarantine of jail prisoners had defense attorneys crying foul in Riverside County, California. Al-though constitutional law requires an arraignment within 48 hours of arrest, pretrial detainees were not being taken to court due to the quarantine.

“It’s not that clear cut that just because somebody is ill you can’t provide a courtroom that accommodates that,” said assistant public defender Bryant A. Villagran. “They may have an obligation to protect the people from that risk [of swine flu], but that doesn’t necessarily mean they have the right to stop somebody’s due process.”

... So Goes the Nation

At least one defense attorney in Washington state’s Spokane County had no problem with postponing hearings for prisoners who might be infected. The unidentified lawyer requested a one-day delay and refused to sit next to his client, who appeared in court wearing a surgical face mask. The mask was required by jail officials because he shared a cell with other sick prisoners.

While that defense attorney may have overreacted, the threat posed by swine flu is real. Kenneth Lane Beckett, 27, a Harris County, Texas jail prisoner, died on September 25, 2009 after contracting H1N1. He was awaiting trial on murder charges.

As with most deaths resulting from swine flu, Beckett had other health problems. “He had underlying serious medical conditions along with the H1N1,” said Deputy Thomas Gilliland, a spokesman for the Harris County Sheriff’s Office. Separately, three cases of H1N1 were reported at the El Paso County jail.

There were no confirmed swine flu outbreaks in Texas prisons, the nation’s second largest state corrections system, as of May 2009. “We’re testing people who may be symptomatic, but we have no confirmed cases of swine flu,” said Texas Department of Criminal Justice spokesman Jason Clark. “It’s something we’re monitoring and something we’ll continue to look at.”

As a precaution, weekend visitation at all 112 Texas prisons was suspended in May and newly-arrived prisoners were quarantined for 72 hours. By October 2009 there were 23 confirmed cases of H1N1 among Texas state prisoners, most at the Estes Unit.

The state with the third most populous prison system, Florida, experienced an outbreak of swine flu in July at the Lancaster Correctional Institution, which houses about 500 male offenders between the ages of 19 and 24.

“I don’t know the actual number who got sick,” said Dr. Pamela Santelices, a local physician, who advised that all prisoners with symptoms were isolated and treated after a cluster of three cases was reported.

There were six confirmed and 17 suspected cases of swine flu at the Homestead Correctional Institution in Dade County, Florida, which houses 668 women. Visits at the facility were suspended and 252 prisoners were quarantined in their units.

Once a cluster of confirmed cases is found, no more testing is done. “According to the guidelines of the Centers for Disease Control, further testing of additional cases in the facility is not necessary because of the similarity of symptoms and proximity of the victims,” said Gretl Plessinger, spokeswoman for the Florida Department of Corrections.

Three county jails in Florida had confirmed outbreaks of swine flu. Pasco County reported one case, there were three confirmed and four suspected cases in Collier County, and Pinellas County had seven confirmed and 25 suspected cases. Three immigration detainees at the Krome Detention Center in Miami tested positive for H1N1.

Swine flu also has been reported in prisons and jails in Kentucky, Idaho, Nevada, Pennsylvania, New York, Maine, South Carolina, Tennessee, Arizona, Illinois and Massachusetts, often resulting in quarantines or visitation restrictions.

The U.S. Bureau of Prisons implemented a four-part response plan that included screening all incoming prisoners for flu-like symptoms. Several federal facilities canceled or suspended visits, and there were confirmed cases of H1N1 at FCI Tucson in Arizona, USP McCreary in Kentucky, and FCI Memphis in Tennessee.

In May 2009, the Cook County Jail in Chicago, Illinois arbitrarily limited visits to immediate family members over age 18; similar restrictions were imposed in December following 26 confirmed cases of H1N1 at the facility.

That exaggerated response – as though family members were somehow less susceptible to swine flu – was typical of such knee-jerk reactions. If officials were serious about containing H1N1 there would be no movement in or out of quarantined prisons and jails, including by staff members, until the threat of infection had passed.

“Jails and prisons are part of communities,” said Ed Harrison, president of the National Commission on Correctional Health Care. “If they think that disease won’t spread from there – when you have visitors, workers and delivery people there every day – they’re mistaken.”

One court has recognized the futility of restricting visitation due to swine flu-related fears. On December 23, 2009, Montana’s Supreme Court struck down a Missoula County jail policy that suspended contact visits based on concerns about spreading the H1N1 virus. The Court held that the jail’s policy infringed on prisoners’ right of access to the courts by limiting them to non-contact attorney visits, but said officials could “impose reasonable public health precautions such as masking and hand sanitizing to reduce the risk of infection.”

The policy, which had been implemented on October 27 for the “duration of the flu season,” was challenged by the state public defender’s office. Jail officials were ordered to immediately change the policy to allow private, in-person attorney visits. See: Office of the State Public Defender v. McMeekin, 2009 MT 439 (Mont. 2009); 2009 Mont. LEXIS 678.

There is no question that officials should act promptly and appropriately when confronted with outbreaks of H1N1, however. The Middlesex County Jail in Cambridge, Massachusetts, which holds about 400 prisoners, was faced with a near-riot situation after a confirmed case of swine flu was quickly followed by ten prisoners and two guards who exhibited flu-like symptoms.

The prisoners – who were packed into an overcrowded jail that was designed to hold 160 – were legitimately concerned about a heightened risk of the virus spreading due to cramped conditions. In addition to the cell blocks, they were being housed in the jail’s chapel, indoor gym, visitation room and hallways. On July 5, 2009, nine prisoners created a disturbance and broke the sprinkler heads of the fire suppression system at the facility, causing extensive damage.

“The flooding went down from the 18th floor all the way through the building into the lobby and it was cascading down the elevator shaft,” said Sheriff James DiPaola. Electricity to the jail had to be cut off and approximately 200 prisoners were moved to other nearby facilities. Four Middlesex County prisoners face charges as a result of the incident.

At the Berks County Prison in Pennsylvania, 90 female prisoners were locked down in October 2009 after six developed flu-like symptoms. The quarantine resulted in the delay of a murder trial because a witness was being held at the facility. “It caused some slight disruption in the court system,” said District Attorney John T. Adams. “I firmly believe that with the dangers of the flu we have to take precautions.”

The November 2009 death of an unidentified female Pennsylvania prisoner at SCI Cambridge was blamed on H1N1. She had chronic obstructive pulmonary disease, which increased her susceptibility to swine flu. Another Pennsylvania state prisoner, Howard “Duck” Kelley, 25, who was serving a life sentence, died at SCI Dallas on November 14 after being exposed to the virus.

In June 2009 the Rikers Island jail complex in New York City reported 64 cases of swine flu among prisoners, plus five involving jail employees. Confirmed cases of H1N1 were also reported at jails in Syracuse, New York and Cumber-land County, Maine.

Swine flu has been found in detention centers outside the U.S., too. Up to 70 prisoners displayed flu-like symptoms at Australia’s Queensland prison; a subsequent quarantine required court approval for prisoners to leave the facility. Three confirmed cases of H1N1 occurred at the Rimutaka Prison in New Zealand, and on December 27, 2009, forty-five new cases of swine flu were reported at the Butimba Prison in Tanzania. Five suspected cases of H1N1 were found at the Kigali central prison in Rwanda in early January 2010; as a result, visitors were required to undergo medical screening and wear face masks.

While there were few media reports of swine flu among prisoners in the United Kingdom (one case was confirmed at Sudbury Open Prison in July), there were reports of prisoners drinking alcohol-based hand gel sanitizer in an attempt to get drunk. The hand gel had been distributed in an effort to prevent the spread of H1N1.

“It was subsequently reported by some association members ... that the inmates had been incorrectly using [the sanitizer], for want of a better phrase,” said Andy Fear, a member of the Verne Prison Officers Association.

Prisoners in Ontario, Canada were scheduled to receive the swine flu vaccine on November 1, 2009, while vaccinations for guards were canceled due to poor turnout among staff for flu shots in previous years. An officer at the Toronto West Detention Centre called the decision to inoculate prisoners but not prison guards “insulting.” The Toronto West facility was placed on lockdown for three hours on November 2 after guards protested by initiating a “work refusal.”

Vaccination Controversies

The institutional response to treating and stopping the spread of swine flu has included quarantining people infected with the virus; prescribing Tamiflu, an antiviral medication; and, most recently, H1N1 vaccinations. The CDC “recommends influenza vaccination as the first and most important step in protecting against the flu.” Vulnerable populations were slated to receive the vaccine first, including pregnant women, children and young adults, and adults with certain chronic health conditions.

Prisoners who fall within those high-risk categories are also priority cases for vaccinations, but not all prisoners are considered high-risk based solely on the fact of their incarceration. “Whether to offer it [the vaccine] to prisoners is up to state public health officials,” said CDC spokesman Tom Skinner.

The H1N1 vaccine was approved for use in the United States on September 15, 2009, and distribution began in October. Although there were initial shortages there is now a surplus of swine flu vaccine.

Despite a public outcry, Massachusetts officials, recognizing the danger of a potential outbreak in the close confines of the state’s prison system, decided to vaccinate thousands of prisoners before providing the vaccine to other citizens.

The Hawaii DOC announced in November 2009 that prisoners at high risk of catching swine flu would receive vaccinations before the general public. “The sooner we can vaccinate, the sooner we’ll be more comfortable,” said Dr. Marc Rosen, medical director for the Hawaii Department of Public Safety.

A December 10, 2009 news report indicated that 40,000 doses of vaccine were headed to California prisons, which house about 168,000 prisoners. The Metropolitan Correctional Center, a federal prison in San Diego, received 20 doses of vaccine while 400 doses were going to jails in San Diego County.

Maryland officials said 1,900 vaccinations would be provided to state prisoners and prison staff, and the Florida DOC ordered swine flu vaccine for distribution to high-risk prisoners. However, Oklahoma health officials denied the state prison system’s request for 15,000 doses of vaccine, saying high-risk cases in the general population would be given priority.

In Virginia, prisoners at the Hampton Roads jail will be vaccinated but not those at the jail in Portsmouth. “When you’ve got law abiding citizens and tax payers out there that have to wait in line behind inmates, I think the law abiding citizens have the right to the serum first,” said Portsmouth Sheriff Bill Watson. He was told by the Virginia Department of Health that prisoners will receive swine flu vaccine only when it is distributed to the general public.

Likewise, prisoners at the Gaston County jail in North Carolina will not get H1N1 vaccinations before they are made available to members of the public. Officials cited the transient, short-term nature of jail stays as one reason why prisoners were not considered a priority for vaccinations.

A mere 300 doses of H1N1 vaccine were distributed to the Nevada DOC and of those only 10 went to prisoners. “There are people who will say, ‘They’re just prisoners. Who cares?’” said Allen Lichtenstein, general counsel for the Nevada ACLU. “But this isn’t just a problem for inmates. If this epidemic spreads among thousands in there – and it easily could in the overcrowded conditions that are present – the state is going to be faced with how to deal with this.” There have been eight confirmed cases of H1N1 in Nevada prisons.

In October 2009, the Wisconsin DOC responded to criticism that some prisoners would receive swine flu vaccinations before the general public. Wisconsin’s prison system, which houses 22,000 prisoners, received 900 doses of vaccine. Forty-five went to prisoners, including pregnant women at the Taycheedah Correctional Institution. “No one wants to be inhumane,” complained state Rep. Brett Davis, “but there are pregnant women who have been law-abiding citizens who are having trouble getting the vaccine.”

Christopher Ahmuty, director of the ACLU of Wisconsin, disagreed. “In overcrowded jails and prisons ... the risk of H1N1 contagion spreading among prisoners and correctional officers and then to the officers’ families and communities must be addressed vigorously,” he said. “Prisoners are serving their debt to society, but being subjected to disease and death is not part of a just sentence in any civilized society.”

Although healthcare officials in Texas initially declared that high-risk prisoners would receive vaccinations, they reversed that decision on October 28, 2009 following extensive criticism. “Texas has not allocated any swine flu vaccine to prisons at this time,” the Department of State Health Services announced. “Prisoners are not a priority group to receive the vaccine and will not be vaccinated ahead of the general public.” Some high-risk prisoners were still slated for vaccinations, though, including those who were pregnant “to help protect their unborn children.”

“Not allocating any swine flu vaccine to prisons at this time doesn’t seem like a good answer,” said Texas state Rep. Jim McReynolds, who chairs the House Corrections Committee and sits on the House Public Health Committee. “Like it or not, we have a large number of people incarcerated in Texas – in [the Texas Department of Criminal Justice], in [the Texas Youth Com-mission], in various mental health facilities. We have a responsibility to take care of the people there, the ones who are vulnerable to this illness, the ones who are medically fragile.”

The U.S. military said it planned to offer vaccine shots to 200 political detainees at the Guantanamo Bay prison in Cuba. This led to criticism from U.S. Rep. Bart Stupak (D-MI), who slammed the government for putting incarcerated guerrilla suspects before U.S. citizens – even though all but one of the Guantanamo detainees have not been convicted of any crime. Pentagon spokesman Bryan Whitman later said the detainees would receive the vaccine only after active duty military troops and other Dept. of Defense personnel were vaccinated.

Beyond H1N1

There has been a great deal of media attention focused on swine flu due to the global pandemic. However, consider that H1N1 is much less of a threat than other maladies that commonly affect prisoners, such as HIV/AIDS, hepatitis C (which has reached epidemic levels in some prison systems), MRSA and tuberculosis. [See: PLN, Nov. 2007, p.1].

While prison and jail officials have taken steps to prevent the spread of swine flu, including temporary quarantines in some cases, historically they have been less inclined to provide comprehensive medical care for prisoners who suffer from HIV/AIDS or hep C – which result in far more fatalities.

According to a study released by the Bureau of Justice Statistics in December 2009, for example, over 22,100 cases of HIV were reported among state and federal prisoners at yearend 2008, including 5,113 that had progressed to AIDS. In 2007, the most recent year that death-in-custody statistics are available, 130 prisoners died from AIDS-related causes alone. Other prisoners have been denied routine medications such as antibiotics and insulin, resulting in needless deaths.

Once the focus on swine flu subsides, prisoners will continue to die from treatable and preventable medical conditions due largely to the apathy of prison officials, despite a constitutional obligation to provide prisoners with adequate health-care.

Sources: Centers for Disease Control, St. Petersburg Times, Miami Herald, Associated Press, Gainesville Sun, Idaho Spokesman, News-Sentinel, Desert News, Orange County Register, USA Today, Augusta Chronicle, Sun Journal, Mercury News, news.smh.com, www.monstersandcritics.com, Houston Chronicle, Los Angeles Times, San Francisco Chroni-cle, Boston Globe, www.corspecops.com, http://cbs5.com, http://bjs.ojp.usdoj.gov, www.starbulletin.com, www.cbsnews.com, http://wjz.com, www.statesman.com, www.canada.com, Las Vegas Review-Journal, www.madison.com, www.readingeagle.com, Wilkes Barre Times-Leader, www.afriquejet.com, www.torontosun.com

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