California Prisons Limit the Use of CPAP During COVID-19 Crisis
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California Prisons Limit the Use of CPAP During COVID-19 Crisis
California prisons have been disconnecting CPAP machines and removing them from dormitories in an attempt to reduce the number of COVID-19 infections, according to an article published last weekend in the LA Times. Despite limited testing capabilities at the majority of the state’s correctional facilities, prison authorities are attempting to abide by the FDA’s recommendations for “environmental controls” by simply limiting the use of CPAP among inmate populations. The controversial decision has led to complaints by inmates in need of the devices to treat sleep apnea and other potentially life-threatening conditions. While the California Department of Corrections and Rehabilitation (CDCR) have insisted that their CPAP reduction program is voluntary, inmates argue that they have little choice but to concede with the request, given that they risk possible transfer to another prison or to a more isolated area of the institution where their current jobs may not be available. The controversy continues as inmates advocate for their rights as patients and as citizens, many of them dependent upon PAP-therapy devices for treatment of serious health conditions, breathing difficulties, and sleep problems. Amid an already volatile climate of fear and misinformation surrounding the COVID-19 pandemic, the situation has become highly contentious, and both patients and doctors have voiced concerns about the potentially harmful effects of discouraging treatment compliance during an international health crisis.
The CDCR’s goal for the CPAP reduction program is to reduce COVID-19 infections, which they view a greater risk to the health of inmates than the individual conditions of those using CPAP. The exhalation of air during PAP therapy, described as “aerosol-generating procedures'' by the department, is seen as an infection risk in confined sleeping arrangements. In response, the department has distributed a number of “request” forms asking inmates to allow their CPAP machines to be disconnected by prison authorities. While the CDCR claims that it will not disable CPAPs that are deemed "medically critical,” it will, however, take other precautionary steps in those cases, including moving the inmate to another housing arrangement such as a cell. How they decide if a patient’s need is “medically critical” depends on the assessments of prison medical staff and may vary from case to case. As defined by the Medicare Glossary, “health services or supplies are “medically necessary” if they are needed to “diagnose or treat an illness, injury, condition, disease, or its symptoms, and that meet accepted standards of medicine.” There is no question of PAP-therapy’s benefits as the gold standard of treatment for sleep apnea, but its impact on underlying conditions can in some cases be even more critical to a patient’s health needs.
KPCC radio in California has reported that widespread increases in demand for medical attention in jails and prisons has led to constraints in the systems, limiting treatments for non-coronavirus as well as coronavirus-related health needs. In some cases, this has even led to the early release of some inmates with minor charges. As the state struggles to keep up with the rising demand for health services, programs such as the CPAP reduction drive have been implemented as a temporary solution that many are questioning as a possibly inefficient and ill-informed choice of policy.
The form that inmates are asked to sign gives consent for prison officials to disable their CPAP by removing its electrical cords. While the form itself specifies that inmates can notify medical staff to request the return of the cords, the policy encourages inmates to abide by the request, thereby encouraging nonadherence to treatment. Maintaining treatment compliance can be challenging for patients in any setting, but in a prison environment in the middle of an international disease pandemic, the issue can be extremely controversial.
As mentioned in our previous article on CPAP safety during the COVID-19 pandemic, it is important to take precautions when infection is a possibility, but the risk of a patient infecting others by using CPAP is only an issue if the patient enters public areas where there is potential for infection. According to an article published on the Laist.com website, medical experts are now speaking out against the CDCR’s policy of removing CPAPs.
Dr. Richard Castriotta, a leading sleep expert at Keck Medicine of USC, told reporters at Laist.com that the risk of CPAPs infecting inmates is "negligible compared to the risk that they're all breathing each other's air all the time anyway.” While Dr. Castriotta did acknowledge that a loosely fitted or leaking mask could raise the risk of spreading the virus in confined spaces, he also pointed out that a patient would have to be infected for this to be a concern. On properly fitted masks, expiratory airflow is filtered through the system and not all that different from simply breathing near someone. In fact, “the increased odds of a heart attack or stroke for someone who stops using the machine is a greater risk,” the doctor said, adding that “70 percent” of people who have a stroke also have sleep apnea. But the CDCR disagrees, arguing that the risk of exposing others through PAP-therapy devices “outweighs the risk of temporarily taking someone off CPAP.”
Dr. Castriotta suggested that the best thing prisons can do in this situation is reduce the unfortunate crowding that endangers inmates regardless of the coronavirus outbreak. California prisons, like many correctional institutions across the country, are often crowded with inmates sleeping close to one another in dorms as well as in individual cells. In addition to the coronavirus, many illnesses are spread throughout the institutions at a rapid rate, not only endangering the health of the patients but also adding to the cost of incarcerations.
As of last Sunday, the 26th of April, at least 120 state prison staffers and 176 inmates had tested positive for COVID-19, according to the CDCR’s live tracker for the virus. These infection rates do present a problem for prison officials as well as the inmates, and no easy answer exists. But if reports are true that inmates are experiencing consequences for choosing to retain their CPAP machines, the policy could be doing more harm than good.
FDA Letter to Medical Staff - https://www.fda.gov/medical-devices/letters-health-care-providers/ventilator-supply-mitigation-strategies-letter-health-care-providers
CDC Sleep Page - https://www.cdc.gov/sleep/index.html
CDCR.CA.gov - https://www.cdcr.ca.gov/covid19/cdcr-cchcs-covid-19-status/
Keck.usc.edu - https://keck.usc.edu/faculty-search/richard-castriotta/
KPCC - https://www.scpr.org/news/2012/03/09/31581/californias-prisons-see-increased-demand-medical-c/
Laist.com - Full Report - https://laist.com/2020/04/16/coronavirus_california_state_prisons_sleep_apnea-cpap_disable.php
LA Times - https://www.latimes.com/california/story/2020-04-25/i-dont-deserve-a-death-sentence-says-inmate-with-coronary-disease-in-chino-coronavirus-prison-hotspot
Medicare.gov - https://www.medicare.gov
Neurology Clinical Practice - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3721244/
StatPearls Publishing - https://www.ncbi.nlm.nih.gov/books/NBK482178/