WASHINGTON, DC—American Indians (AI) and Alaska Natives (AN) have an H1N1 mortality rate that is four times higher than persons in all other racial and ethnic populations combined, a retrospective CDC study found last month.

According to the December 11th Morbidity and Mortality Weekly Report, there were 426 H1N1 deaths from April 15 to November 12 in the 12 states included in the report. Although AI/ANs make up approximately 3% of the total population in those 12 states, they accounted for 9.9% of these deaths. The higher mortality rate among AI/ANs observed in the December report is consistent with other reports of increased influenza-related morbidity and mortality among indigenous populations in other parts of the world during both the current H1N1 pandemic, and during previous pandemics. “After the influenza pandemic of 1918-1919, US government investigators reported that influenza-related mortality rates among AI/ANs were four times higher than the rates observed among persons in general urban populations,” the CDC report stated.

Capt John Redd, USPHS, chief of the Infectious Diseases Branch in the IHS Division of Epidemiology and Disease Prevention and one of the authors of the report, noted that a higher death rate among AI/ANs was not a total surprise. The IHS has observed severe H1N1 disease throughout this flu season. “We had seen, particularly in a cluster of severe disease in Arizona, that there were areas of the country where American Indians and Alaska Natives were having a harder time with this flu,” he told U.S. Medicine. Still, Dr Redd said that while he had “expected the death rate to be higher [among AI/ANs] than other Americans ... I was surprised that it was as high as 4 [times higher].”

H1N1 and Indian Country

The December CDC report stated that the reasons for the higher death rates are unknown, but might be due to a high prevalence of chronic health conditions (e.g., diabetes and asthma) among AI/ANs, which predisposes them to influenza complications. In addition, poverty and delayed access to care were cited as possible influences. The study stated thatAI/ANs are twice as likely to have unmet medical needs because of cost.AI/ANs also have a poverty rate that is twice the national rate and three times the rate for whites among households with children under 18.

Among AI/AN deaths related to H1N1, 81% had high-risk health conditions, compared with 77.6% of persons in all other racial/ethnic populations combined. In addition, a greater percentage of AI/AN who died had asthma (31%) and diabetes (45.2%) than decedents in all other racial/ethnic populations combined (14.1% asthma; 24% diabetes). “People need to get vaccinations, particularly those in the priority groups,” said Redd.

It is also critical that those with risk facIt is also critical that those with risk factors—particularly children and adults with chronic illness—be evaluated early if they have flu symptoms so they can receive antiviral interventions, according to Redd. The CDC recommends prompt empiric treatment for persons with suspected or confirmed influenza that requires hospitalization; progressive, severe, or complicated illness, regardless of previous health status; and/or patients at risk for severe disease. Those at risk for severe disease include children younger than 2 years old, adults 65 years or age or older, pregnant women, and women up to 2 weeks postpartum (regardless of how the pregnancy ended: live birth, pregnancy termination, preterm birth, miscarriage, fetal death), and persons with certain medical conditions (diabetes, asthma, etc).

Redd said that in response to the findings of the report, the IHS has “redoubled” its efforts in terms of educating providers on early use of antivirals, particularly in patients with risk factors. In addition, the IHS is continuing to emphasize vaccination.

Keeping Track of Illness

The IHS is using an electronic-based system called the IHS Influenza Awareness System to track Influenza-Like Illness (ILI) and ILI hospitalization. “We have been keeping very careful track of where ILI has been occurring in the Indian Health Service, where hospitalizations are happening and where we are having deaths,” said Redd. The system receives data from approximately 60% of IHS sites. “What that system allows us to do is that we are able to see where and when the disease is happening and in whom. We have age data and sex data. The awareness system has allowed us to really keep a very good finger on our pulse,” he said. The IHS is also keeping track of potential adverse reactions to the H1N1 vaccine in American Indians and Alaska Natives, according to Redd.

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