California Prison Health Care Services Public Health Unit INFLUENZA QUARANTINE PROTOCOL– Revised 10/09

1. California Prison Health Care ServicesPublic Health Unit INFLUENZA QUARANTINE PROTOCOL– Revised 10/09

2. Status of Influenza: In CDCR and CA • In CDCR, 20 of the 33 institutions have had significant ILI outbreaks since July 2009. • 370 ILI cases reported between Jul 09 and 09/23/09; • 88% of outbreaks from 17 institutions were confirmed for H1N1 Influenza; ~ 15 hospitalized • CDCR ILI protocols have been very effective in preventing widespread transmission of ILI in prisons. • In California (non prisons), 2698H1N1 reported hospitalized, ICU, or death cases. • Between Jul 09 to 09/25/09. • Number of probable H1N1 in communityis far greater.

3. Current CDCR ILI Protocol • Isolate suspect ILI case until 24 hours post fever and symptoms. • Send Preliminary OutbreakReport to PH Unit. • For initial ILI case and any ILI cases from a new part of the prison. • Gather data using Influenza Case Form. • Send daily line list to PHU when there are two or more suspect cases. • Collect nasal swabs: • Only if two or more suspects per outbreak location; or • If inmate is hospitalized. • Quarantine: • Open dorm or gym unit as soon as single ILI case is identified. • Cell block unit (single or double cells) when two ILI cases identified within 2 weeks of each other. • Maintain quarantine for 7 days, starting from date of last ILI in unit. • Establish heightened surveillance of quarantined unit and nearby areas.

4. Revised ILI Quarantine Protocol* • Quarantine when: • 5 or more ILI SUSPECTSare identified within a 2 week period who are living in the same housing unit. • With fewer than 5 ILI suspects, maintain heightened surveillance in housing unit but do not quarantine. • Isolation = no change in policy. • All suspect ILI cases must be isolated in single cell or cohorted with other symptomatic inmates. • Isolate until 24 hours post fever and symptoms. * as of 10/1/09

5. What ILI Protocols Do Not Change • All other ILI Protocol elements remain the same, including: • Suspect ILI case reporting • To PH Unit and Local Health Department • Enhanced Surveillance • Clinic nursing staff conduct daily inmate symptom review for each new outbreak location. • Nasal swab protocol • Isolation Procedure • Isolate in Ad Seg, single cell, or in a designated isolation area • Greater than 6 feet away from well inmates; and/or • Inmates are masked when required to be closer to other people. • Once 5 suspect cases are identifiedwithin a two week period in the same housing unit, quarantine duration remains the same (i.e., 7 days from last ILI case). • Submitdaily line lists for outbreaks (2 or more cases) • Include dates and housing unit on line list.

6. Why Revise the Quarantine Protocol? • Recommended by CDPH. • In past 3-4 months when inmates were rapidly isolated, the rates of transmission in the quarantine areas have been low. • Current evidence suggests that a less restrictive quarantine will be safe and not result in large outbreaks (could change!) • PH Unit will closely monitor to determine if there is an uptick in large outbreaks after new protocol is implemented. • Secondary gain: Improve inmate morale/compliance with quarantine over duration of influenza season (6 months). • Encourages ill inmates to seek medical attention promptly.

7. PHN/ICN Leadership Responsibilities • Continue regular surveillance, training, and flu prevention programs. • Lead vaccination campaigns throughout Fall/Winter. • Provide timely reports: outbreak and line lists. • Continue to work with leadership to identify effective isolation areas for sick inmates. • Plan for alternative quarantine sites (outside of normal housing units) for possible mass pandemic surge.

8. Questions