WASHINGTON—The Indian Health Service is making sure that its health facilities are ready to deal with a possible widespread outbreak of H1N1 in the fall. “We are not letting our guard down now. I see a lot of people kind of backing off and it is not in the news as much, but we are staying focused on it…We are focused on the fall to make sure we are prepared,” said Cdr Darrell LaRoche, USPHS, IHS director for Emergency Services.

As of June 19th there were about 50 American Indian and Alaska Natives who were confirmed to have H1N1 flu and two fatalities. However, IHS officials said the estimate of infections is likely the “tip of the iceberg,” since some infected individuals may not have been diagnosed. LaRoche said that the agency is well positioned to deal with a potentially more widespread outbreak of H1N1 should it occur. In 2006 the agency had put together a pandemic influenza workbook that detailed how a flu outbreak would be dealt with. “The Indian Health Service really started actively planning for pandemic influenza back in 2006. One of the projects was to prepare a pandemic influenza workbook for American Indian and Alaska Native communities,” he said. “We started to collect the data, as far as who do you need to talk to during an outbreak, how do you look at the surveillance, the vaccine and antiviral distribution, workforce support, communication, and things like that. It was a good planning guide.”

Dealing with H1N1

The World Health Organization declared H1N1 a pandemic in June, but by that time IHS, like other agencies, had already been working to curtail the spread of the virus. In IHS, daily conference calls to Indian officials around the country were conducted to make sure that leaders were briefed on the situation, and that the health facilities had the protective equipment and antivirals that they needed. “By the time they declared it a pandemic, we were, in the United States at least, looking at it being fairly widespread,” LaRoche said.

Guidance to healthcare workers on what they could do to protect themselves and patients were also provided to facilities, La-Rouche said. “During the first wave [of H1N1], what we relied on heavily was the information coming out of CDC, because we were looking for that unifed message from the federal government,” he said. “So the office of Personnel Management had sent out a lot of guidance and CDC had their guidance on protecting health care workers and other workers. Each of the facilities would be providing briefings to their staff on what they can do.”

Making sure that IHS employees who may be at risk of exposure to patients with H1N1 is a big part of influenza planning, according to Dr John Redd, chief of the Infectious Diseases Branch at the IHS Division of Epidemiology and Disease Prevention. “Personal protective equipment is a big part of our planning for employee protection because if employees get sick they can’t take care of anyone. We also stress our plan for sick employees to stay home, which is a surprisingly important measure in flu outbreaks,” he said.

Working With States

The H1N1 outbreak earlier this year put the plans the agency had in place to the test, and allowed it to see what areas it needed to work on for the fall. “This was kind of a good real world test of all of our plans considering the H1N1, or at least this first wave wasn’t as severe as it could have been,” he said.

One aspect of influenza planning that is being strengthened is making sure that IHS and tribal facilities know how to work with their states to receive influenza supplies. IHS and tribal facilities receive many supplies through the Strategic National Stockpile, which is distributed by the states. “It is the state’s responsibility for the distribution,” he said. “Many times the tribal communities, since they are in small pockets in remote areas, aren’t included in the plan, or there is not a really good plan to get the items out to them. It varies from state to state, depending on who the coordinators are and what their planning has been up to this point. We are making sure that the each of our individual facilities and the tribal facilities are definitely included in the distribution and they know the exact process.”

In addition, the agency is also working on vaccine distribution plans for employees and patients once a vaccine is produced for H1N1.

Flu Surveillance

Doctor Redd said that while he is confident that the agency can respond to a potentially greater H1N1 outbreak, at this point it is uncertain what the situation will look like in the fall. “I am confident that we can respond to it, but the problem is that no one knows how bad it will be,” he said.

One important way in which the agency is preparing is through a surveillance system for influenza that it set up during the H1N1 outbreak earlier this year that allows the agency to track H1N1 cases. “Early in this outbreak, we thought maybe we should use the information that IHS collects during clinical visits as a way to try to see where influenza might be happening in IHS, because of course we have facilities all over the country,” Dr Redd explained.

The surveillance system should be especially helpful to the agency in allowing it to know very quickly where influenza activity is occurring. If the surveillance system detects increased flu activity in an area, IHS officials would be able to warn local officials and make sure that the area is equipped to deal with the situation. “We would send out messages to clinical doctors or nurses who are seeing patients in that area to tell them to be mindful for flu,” said Dr Redd. “We would make sure they would have antiviral materials, things like that. So there are lots of things we would do to move things into place if we were worried that influenza activity was picking up somewhere in the Indian Health Service.”