A letter issued by Centers for Disease Control and Prevention director Thomas Frieden M.D. has advised the states that American Indians and Alaska Natives may be more vulnerable to severe illness from H1N1 influenza and should receive vaccine on a priority basis.

Frieden writes that indigenous populations from Australia, Canada and New Zealand have a three to eight times higher rate of H1N1-related hospitalization and death, and that two states in particular, Arizona and New Mexico, observed a disproportionate number of H1N1 deaths in American Indians.

His letter urges state health officers to redouble their efforts with minority providers to increase H1N1 vaccinations among underserved populations.

A CDC report issued Dec. 11 indicates from April 15 to Nov. 13, American Indians including Alaska Natives in 12 states died from H1N1 at a rate four times higher than other races or ethnicities.

The American Indian H1N1-related death rate was 3.7 per 100,000 compared with 0.9 per 100,000 for all other racial/ethnic populations. It said reasons for the disparity are unknown, but might include a high prevalence of chronic health conditions such as diabetes and asthma, and delayed access to health care. Many of the deaths occurred before a vaccine was available.

“We’ve been worried from the very beginning,” said IHS epidemiologist and report co-author John Redd M.D. “We knew from previous outbreaks that there was severe disease happening in AI/AN and other indigenous populations.”

Redd noted the report’s recommendation that there be an expansion of efforts to promote vaccination in American Indian populations, and said the IHS has an excellent vaccine delivery system.

The IHS suffered delays in vaccine distribution to the same degree the rest of the country did, and while current distribution varies state by state, “We know it’s widely available now, and we’re asking people to contact their health facilities and get vaccinated.”

Individuals can be vaccinated against both the seasonal flu and H1N1 influenza vaccine at the same time, and should ask their clinic for the pneumonia vaccine if they haven’t received that.

The report is recommending stronger efforts to increase awareness among American Indians and their health care providers of the potential severity of influenza, and the current recommendations regarding timely use of antiviral medications. That is currently a problem for patients with health care providers unfamiliar with the report or IHS policies.

A large urban IHS-funded medical clinic told a patient stricken with the flu Dec. 17 that they were not treating patients with antivirals unless they were in the hospital. The clinic said they were following the policy of the CDC but, “That’s not consistent with our policy,” Redd said.

While clinicians have latitude with their patients, the IHS policy is that antivirals are appropriate for people in risk groups both as outpatients and as inpatients.

In addition to AIs/ANs, those at highest risk of H1N1 complications are pregnant women and those with chronic conditions such as diabetes, heart disease, asthma or other conditions that reduce immunity to influenza. Other groups at higher risk of infection or who can spread the virus to vulnerable populations are health care workers, people between the ages of 6 months and 24 years and caregivers of children ages 6 months and younger.

Influenza is widespread in all 50 states, and 99 percent of it is the H1N1 strain. Nearly all cases respond well to the antiviral drugs oseltamivir and zanamivir if treated within the first 72 hours after symptoms appear.