Influenza Vaccination and Migration at the US Southern Border

In the past year, at least three children who migrated across the US southern border in the custody of Customs and Border Protection (CBP) died with laboratory-confirmed influenza infection as a contributing factor.¹ The first was Felipe, an eight-year-old boy from Guatemala who died in December 2018 upon arrival to the hospital after being diagnosed with influenza B earlier in the day. The second was Wilmer, a two-year-old boy who died in May 2019 after an eight-day admission to the pediatric intensive care unit, where he had tested positive for influenza A. The third was Carlos, a 16-year-old boy who was diagnosed with influenza A in May 2019 at a CBP Centralized Processing Center. He was given oseltamivir and transferred to another detention facility in isolation, where he was found dead in his cell less than 24 hours later.

After inquiries from members of Congress, CBP disclosed that border facilities neither require influenza vaccination for staff nor offer influenza vaccine to migrants. Examining the agency’s decision provides a window into US immigration policy and priorities at the southern border.

Influenza and other infectious diseases are serious risks in every congregate living facility, but detention poses special additional risks. Introducing cohorts of susceptible detainees into a closed community creates a “revolving door effect,” in which newly arriving people are quickly exposed to each other and to those already in the facility.² Documentation of overcrowding, lack of access to soap and water, and inadequate infrastructure to isolate sick people in US detention facilities indicate that living conditions may be contributing to the spread of infectious diseases in detention centers. In addition to the deaths from influenza, there have been reported outbreaks of other infectious diseases, most notably mumps, with almost 900 confirmed and probable cases across 57 facilities run by Immigration and Customs Enforcement from September 2018 to August 2019.³

A range of actions would reduce these risks substantially. Basic steps would include surveillance for infectious diseases, prompt triage, early treatment, isolation, and improved medical monitoring of sick people. Vaccination of staff would reduce their risk as well as the risks to the detained population. In the case of influenza, vaccination of migrants themselves would reduce the incidence of disease and its severity.

SO WHY HAS CBP DECLINED TO VACCINATE?

CBP’s explanation is that it is too complicated for the agency to offer the influenza vaccine. An agency spokesperson recently stated, “The system and process for implementing vaccines—for supply chains, for quality control, for documentation, for informed consent, for adverse reactions—is complex, and those programs are already in place at other steps in the immigration process as appropriate.”⁴ Border facilities are the first point of contact for asylum seekers crossing the border; they are meant to serve as temporary shelters, designed to hold individuals for no longer than 72 hours.

In reality, however, as many as one third of children have been held for longer than 72 hours,⁵ including two of the three children who died last year. Moreover, initiating vaccination as quickly as possible can reduce infection rates in other parts of the immigration system. Establishing mass influenza vaccination programs in transitory settings is not prohibitively difficult. Vaccination programs effectively control infectious disease outbreaks in remote refugee camps, which exhibit constant inflow of displaced peoples in addition to a host of logistical challenges that border facilities do not face.

At the end of 2018, the Centers for Disease Control and Prevention (CDC) initiated an investigation into respiratory illness in CBP facilities. CDC found evidence of influenza transmission and recommended a series of control measures, including that CBP offer influenza vaccination to its staff and to individuals in detention at the southern border at the “earliest feasible point of entry to allow for maximum protection of migrant and potential to reduce transmission at Border Patrol Facilities.”⁶ CDC advised that vaccination “may be most feasible at the border stations with current existing medical infrastructure” and that the agency should explore “local community partnerships . . . to support vaccination efforts.”⁶ CDC’s report arrived in January 2019, after the first child’s death, but CBP did not accept the recommendation to initiate vaccination efforts. Several months later, the two additional deaths related to influenza occurred. Most recently, CBP denied requests by community physicians to establish an immunization clinic for detainees.

A CHALLENGE TO PUBLIC HEALTH AND MEDICINE

CBP’s decision not to offer influenza vaccination despite multiple fatalities is one of several policies adverse to health evident at the southern border. There is ongoing litigation against the agency about the standards of detainment, the adequacy of infectious disease control, and the adequacy of the medical care provided in federal custody. There are also other ongoing controversies about the health impacts of recent immigration policies themselves, including the separation of thousands of children from their families and recent decisions to keep people seeking asylum outside of the United States during the immigration process.

In this context, the failure to immunize against influenza is more than a refusal to offer a basic measure to prevent illness and death. It signifies a lack of respect in US immigration policy for the health of people migrating and seeking asylum at the southern border, as well as for the agencies and health professionals who care for them. It reflects the diminishment of values that are core to the fields of public health and medicine. And it stands as a challenge to these fields—and to their practitioners—to advocate for change.