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By Jeffrey E. Keller, MD, FAACP
Border detention facilities that house immigrants have been in the news recently because of their policy of not providing influenza vaccinations to their detainees, sparking high-profile protests. Why would an immigration detention facility, tasked among other things with providing comprehensive medical care to its detainees, refuse to provide them with flu vaccines?
To answer this question, it might be instructive to ask how influenza vaccinations are handled at other prisons and jails in the U.S. It depends on what type of facility you are in and how long you will be there. All prison systems I know of offer influenza vaccinations to their inmates. On the other hand, most jails (short-term detention facilities) do not have a routine flu vaccination program, though there are exceptions.
Vaccinations in Prisons
Inmates are sentenced to prison for a minimum of one year and usually longer. As a result, prison populations are stable. Almost all of the inmates in a particular prison now will still be there next year. Also, prisons are tasked with providing comprehensive medical care to their inmates. This includes influenza vaccinations, but also other recommended vaccinations and boosters. Of course, just like in the community at large, not all inmates want to be vaccinated. The percentage of prison inmates who get vaccinated depends on how vigorously the prison pushes the program.
If a prison advertises the availability of the flu vaccine and actively encourages its inmates to be vaccinated, the acceptance rate can be greater than 50% (compared to about 33% of adults in the community who get vaccinated). Most prisons have a “big push” campaign to encourage flu vaccines once a year in the fall. However, if a prison does not advertise the availability of the flu vaccine, the percentage of inmates vaccinated can be very low. It makes economic sense for prisons to actively encourage their inmates to be vaccinated. Every dollar spent on influenza vaccinations will save more than a dollar down the road trying to deal with influenza outbreaks.
Vaccinations in Jail
Influenza programs in jails are different for several reasons. The first issue is that the inmate population in a jail is not stable. The average length of stay in the average jail in the U.S. is around 2-3 weeks and many are released within days. If a jail offers influenza vaccinations in October, most of the inmates vaccinated will be gone by November. The jail will now be filled with new, unvaccinated inmates. If you vaccinate the November inmates, most (again) will be gone by December. So, to be effective, influenza programs in a jail must last the length of the influenza season — making jail influenza programs more difficult and expensive to administer than a prison program.
As an example, remember that one must order influenza vaccines well in advance. In order to have influenza vaccines ready in the fall, a prison or a jail has to order them at least six months earlier. A prison will know how many influenza doses it will need based on its population and previous acceptance rate. But how many doses will a jail need with inmates coming and going over the course of an entire flu season? That can be hard to get right in a jail! It is expensive and maddening to order too many vaccines only to throw the unused doses away at the end of the flu season.
Also, jails vary greatly by size and sophistication of the medical services they provide. There are many small jails in the U.S. (think 10 beds) where no medical personnel ever come to the jail for routine medical care. If their inmates need medical attention, the deputies have to load them into a van and take them to a clinic or ER in the community. Such a jail is unlikely to offer influenza vaccinations to their inmates. On the other hand, bigger jails (say, more than 1,000 beds) with a full-time medical staff may indeed have an influenza vaccination program.
“Kicking the Can Down the Road”
The most successful jail influenza programs that I have seen are done in cooperation with the local health department. The health department is tasked with providing vaccinations to the community at large, which includes jail inmates. When asked, health departments often will come to the local jail once a month to provide influenza vaccinations to any inmate who requests one. (This is also a good way to provide screening for sexually transmitted diseases in asymptomatic inmates.) Even small jails can approach their local health department about providing immunizations to inmates, though few do.
Customs and Border Patrol reportedly defended its policy of not providing influenza vaccinations during border detention by saying that immigrants are only there for a few days and are expected to get the flu vaccine later, when they are moved to a long-term facility. Where I grew up, this was called “kicking the can down the road.” To my mind, deferring vaccinations until later makes little medical or financial sense. Since none of these detainees is going to be released, and since you are going to vaccinate them later anyway (as reported), why not do it as part of their initial medical screening?
Jeffrey E. Keller, MD, FACEP, is a board-certified emergency physician with 25 years of experience before moving full time into his “true calling” of correctional medicine. He now works exclusively in jails and prisons, and blogs about correctional medicine at JailMedicine.com.
This post was originally published in MedPage Today.
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