Closely confining people who may be weak and malnourished from an arduous journey sets the stage for an outbreak if flu or other infectious agents are introduced by a new arrival or, perhaps, a facility employee.

“You could not design a more ideal circumstance for the transmission of respiratory viruses and intestinal pathogens because of the close, sustained, person-to-person contact they have within an enclosed environment,” says William Schaffner, MD, a leading vaccine expert and professor of preventive medicine at Vanderbilt University in Nashville.

A letter1 submitted to Congress by clinicians at Harvard University and Johns Hopkins hospital said autopsy results show that three children have died in U.S. custody since December 2018 in part as a result of influenza.

“These children were aged 2, 6, and 16,” the clinician letter states. “These tragic deaths appear to represent more than half of child deaths in the last year in these immigration facilities, and to reflect a rate of influenza deaths substantially higher than that in the general population.”

In addition to influenza, the Centers for Disease Control (CDC) recently reported that from Sept. 1, 2018, to Aug. 22, 2019, there were 898 confirmed and probable cases of mumps in detained migrants.2

The CBP has issued a widely quoted statement that “due to the short-term nature of CBP holding and the complexities of operating vaccination programs, neither CBP nor its medical contractors administer vaccinations to those in our custody.”

There is some speculation that medical care and vaccinations may occur at a later stage of the immigration process, but that could not be confirmed as this report was filed.

“They are not thinking in terms of the individual,” Schaffner says. “They are thinking administratively and bureaucratically. We know that immunity develops over 10 days to two weeks, so some of these children who are less than 8 years old would require two doses of vaccine separated by a month.”

With flu season approaching, time is of the essence.

“All of this is more poignant and pointed because we have had not only the illnesses described, but they have had children who have died of influenza,” he says. “What could be more motivating for them to initiate protection against influenza at the earliest possible moment?”

Indeed, the issue raises a moral and ethical imperative for providers and caregivers.

“CBP actually keeps some people much longer than two or three days. If they are not committed to providing medical evaluations and preventive health services, that’s terribly unfortunate,” Schaffer says. “We as a society have - because of these policies - assumed responsibility for these individuals. They are now our responsibility.”

Several major infectious disease groups also issued a joint statement calling the inaction on immunizations “a violation of the most basic principles of public health and human rights.”3

The statement was issued by the presidents of the Infectious Disease Society of America, the Society for Healthcare Epidemiology of America, the Pediatric Infectious Diseases Society, the HIV Medicine Association, and the American Society of Tropical Medicine and Hygiene.

“The CBP’s decision to withhold vaccinations against seasonal influenza from migrants in border detention facilities … runs directly counter to the imperative that no individual should be harmed as a result of being detained, and that the community standard of medical care be available to persons in the custody of the U.S. government,” the joint statement said.

Since 2010, the CDC has recommended universal flu vaccination for those age 6 months and older.

“In conditions of overcrowding, poor sanitation, and emotional stress involving vulnerable populations such as pregnant women and young children, choosing not to follow the CDC recommendations is particularly egregious,” the infectious disease groups stated.

Infection control in detention

In the letter to Congress, the Harvard and Johns Hopkins clinicians outlined practical infection control measures that should be taken at the detention camps.1 In addition to flu vaccination they recommended the following:

Screening: “All children should be screened for symptoms of influenza-like illness upon intake and transfer to a new facility. Symptoms of influenza-like illness include history of fever with either cough or sore throat. Infants and children with chronic medical conditions may present atypically, without fever and with other symptoms including muscle pain, headache, fatigue. […] Children who screen positive for influenza-like illness symptoms should be considered for immediate isolation. To aid with the detection of new cases, border control staff should be instructed to report children displaying influenza-like symptoms at the first sign of illness.”

Testing: “Children with influenza symptoms should be tested for the influenza virus in accordance with the Centers for Disease Control’s guidelines for investigating influenza outbreaks in closed settings. Testing results should be interpreted using the Centers for Disease Control’s Rapid Influenza Diagnostic Tests interpretation guidelines.”

Isolation: “Children with influenza-like illnesses should be placed in droplet isolation rooms. If separate isolation rooms are not available for each child, children presumed to have the same infection may be placed in the same isolation room.”

Initial treatment: “Children with influenza-like illnesses should receive regular medical assessments to assist with the early detection of complications. Children with these symptoms should receive scheduled temperature checks, access to fluids, tissue and plastic bags for the proper disposal of tissues, and access to soap and water. Frequently touched surfaces in close contact with symptomatic children must be regularly cleaned and disinfected. Toilets and other facilities that are used by such children should be cleaned and disinfected more frequently.”

Antiviral treatment: “Children who screen positive for influenza-like symptoms should be considered for presumptive antiviral treatment with oseltamivir, pending testing for influenza. Treatment is most effective if initiated in the first 48 hours of symptoms, but can still confer benefits after this time period. Children with severe presentations of disease, including respiratory failure and pneumonia, should be immediately transferred to hospital. Children who clinically deteriorate or fail to improve after receiving 3-5 days of presumptive antiviral treatment should also be promptly transferred to a hospital.”

Post-exposure prophylaxis: “Individuals who come into close contact with confirmed influenza cases should be considered for postexposure prophylaxis, which is the preventive medical treatment with oseltamivir to reduce the chance of clinical symptoms developing. Specifically, all children under 2 years of age and detainees at high risk of complications should be offered medication promptly. Oseltamivir is 70-90% effective in preventing illness from influenza A or B viruses.”

REFERENCES

  1. Melinik J, Winickoff J, Sharfstein JM, et al. Letter. August 1, 2019: Available at: https://bit.ly/2kqGPE0.
  2. Leung J, Elson D, Sanders K, et al. CDC. Mumps in Detention Facilities that House Detained Migrants — United States, September 2018–August 2019. MMWR Morb Mortal Wkly Rep 2019;68;749-750.
  3. Sears C, Hardy WD, Babcock H, et al. Customs and Border Patrol’s Flu Vaccine Policy Breaches Basic Public Health Tenet. August 21, 2019. Available at: https://bit.ly/2KYSF1l.