Pandemic: Are We Prepared?

In 2005 I published the article below titled “Pandemic: Are We Prepared?” With the current situation in China and other area our our world, I decided to post it here.

What is a pandemic? Webster’s Dictionary defines the word pandemic as an epidemic over a wide geographic area, affecting a large proportion of the populations. And our history shows there have been several pandemics that devastated millions of people throughout the world.

• 1918-19, “Spanish flu,” [A (H1N1)], caused the highest number of known influenza deaths. More than 500,000 people died in the United States, and up to 50 million people may have died worldwide. This pandemic virus appears to have an avian origin.

• 1957-58, “Asian flu,” [A (H2N2)], caused about 70,000 deaths in the United States. First identified in China in late February 1957, the Asian flu spread to the United States by June 1957.

• 1968-69, “Hong Kong flu,” [A (H3N2)], caused about 34,000 deaths in the United States. This virus was first detected in Hong Kong in early 1968 and spread to the United States later that year. Influenza (H3N2) viruses still circulate today.

As posted on the U.S. Health and Human Services web site, “An influenza pandemic has the potential to cause more deaths and illness than any other public health threat.

“If a pandemic influenza with similar virulence to the 1918 strain emerged today, in the absence of intervention, it is estimated that 1.9 million Americans could die and almost 10 million could be hospitalized over the course of the pandemic, which may evolve over a year or more.”

Pandemics occur when an influenza virus emerges that infects and can be efficiently transmitted between humans. This can start as an animal to animal virus that mutates to humans with or without the animal being the host. Avian viruses played a key part in the last three influenza pandemics.

Today, the biggest threat to the United States appears to be the Avian Flu (H5N1) which has killed over 62 people and infected over 150. It has mostly appeared in European and Asian countries, but transmission to the Americas is a real possibility. Millions of bird, duck and other foul have been slaughtered in attempts to control the spread of the flu. This virus does not jump easily from birds to humans or spread readily among humans. Should H5N1 evolve to a form as contagious as normal influenza, a major pandemic could begin that would have world wide consequences.

According the Washington Post, the deadly strain of bird flu that has devastated poultry and killed more than 60 people in Asia has been detected in a bird in Kuwait, the first known outbreak of the virus in the Gulf region. Tests showed a migrating flamingo found on a Kuwait beach had the lethal and virulent H5N1 strain. A second bird, a falcon quarantined at the airport, had the milder H5N2 strain.

This in itself does not mean the bird flu is going to mutate into the human type, but it demonstrates that it is not limited to one area, and can spread. If this flu mutates into the human-to-human form it could spread across the world in six to nine months, according to World Health Organization.

Chief Medical Officer Sir Liam Donaldson of the United Kingdom warned that a Europe-wide pandemic is “inevitable.” He said 50,000 people would probably die in the UK in the winter of 2006-7 — but a final figure of up to 750,000 was “not impossible.” A study published recently in the open access journal Respiratory Research reveals that, in human cells, the virus can trigger levels of inflammatory proteins more than 10 times higher than the common human flu virus H1N1. This might contribute to the unusual severity of the disease caused by H5N1 in humans, which can escalate into life-threatening pneumonia and acute respiratory distress.

The threat is also being taken very seriously by the United States. The federal government recently announced it is working on a National Strategy in the event of a pandemic. President Bush wrote, “A new strain of influenza virus has been found in birds in Asia, and has shown that it can infect humans. If this virus undergoes further change, it could very well result in the event of a pandemic.

“We have an opportunity to prepare ourselves, our Nation, and our world to fight this potentially devastating outbreak of infectious disease,” President Bush stated.

A National Strategy has been developed to include sections for Preparedness & Communication, Surveillance & Detection and finally Response & Containment. This is based on the emergency management model of mitigation, preparation, response and recovery that has been used for years to combat disasters. This will work as a guideline for the federal government’s operations, but in a pandemic outbreak, weather from N5H1 or any other influenza, state and local governments will also have to be fully involved and integrated into the response.

Preparedness & Communications

This section of the National Plan will include planning to prevent an outbreak, monitoring the progression of any flu, and developing a plan of how to respond.

This will include guidelines for the response of trained health care workers (part of the plan will include the rapid activation and training of these health care providers), with a working distribution plan of the vaccines.

Currently, since N5H1 has not mutated into a human-to-human form there is no preventive vaccine. Manufactures are producing “TamiFlu”; this is not a preventive medicine but can be used within a short period of the development of signs and symptoms of the flu.

Recently, the Swiss drug maker Roche Holding AG said it will increase production of Tamiflu to make 300 million treatments of the antiviral drug annually by 2007, in order to meet government orders amid fears of a flu pandemic. Roche said the increase would mean a tenfold rise in production from 2004.

With the manufactures producing Tamiflu, the next step would be to develop a National Stockpile of the drug to be distributed similarly to the country’s Strategic National Stockpile of medicines (SNS). The SNS is organized for flexible and rapid 12-hour deployment. These stockpiles are positioned strategically throughout the country in secure warehouses, ready for immediate deployment to a designated site.

Another important part of this step is to develop a communication plan to educate the public as to exactly what is occurring and what steps need to be followed for identification and prevention. This should include first responders and other health care professionals.

Ensure that timely, clear, coordinated messages are delivered to the American public from trained spokespersons at all levels of government and assist the governments of other affected nations to do the same.

Surveillance & Detection

During this phase of the National Strategy, we need to develop programs similar to Bio-Shield and other information sharing opportunities with the World Health Organization, other countries and any other groups that monitor the progression of any influenza. Additionally, we need to fully support and expand our research into any reported influenza to control it prior to it becoming a pandemic.

Response & Containment

One of the main challenges will be the coordination from the federal government to the state and local governments. All one has to do is to look at the disjointed assistance that New Orleans received during the critical first days after Hurricane Katrina hit. If it had been a flu outbreak leading to a pandemic the entire country, maybe the world, would have been in significant peril.

A program needs to be developed to ensure that first responders and health care professionals are educated and protected, and that the essential services provided by state and local governments continue. Plans also need to be developed to provide these services in the event of large worker absenteeism. There has been a lot of debate about the use of the military during the recent hurricanes, but military assets and command and control measures may need to be utilized, so these contingency plans need to be developed and tested.

The private sector is also an important stakeholder. The private sector represents a large section of our society because of the services it provides and the employees it employs. Moreover, it touches the majority of our population on a daily basis, through an employer-employee or vendor-customer relationship. For these reasons, it is essential that the private sector be engaged in all preparedness and response activities as a partner for pandemic mitigation, planning response and if needed, recovery.

Some of the responsibilities the private sector can develop include the following:

• Establishing an ethic of infection control in the workplace that is reinforced during the annual influenza season, to include, if possible, options for working offsite while ill, systems to reduce infection transmission, and worker education. This should be instutusionalized in the organization’s continuity of operations plan (COOP).

• Establishing contingency systems to maintain delivery of essential goods and services during times of significant and sustained worker absenteeism.

• Where possible, establishing mechanisms to allow workers to provide services from home if public health officials advise against non-essential travel outside the home.

• Establishing partnerships with other members of the sector to provide mutual support and maintenance of essential services during a pandemic.

The final stakeholder is the general citizenry of the country.

The critical role of individuals and families in controlling a pandemic cannot be overstated. Every medical journal or expert shows that the spread of the flu virus is directly proportional to the individual’s behavior. The spread of disease from one person to another can transmit the virus to tens or hundreds of others. For this reason, individual action is perhaps the most important element of pandemic preparedness and response.

Education on pandemic preparedness for the population should begin before a pandemic, should be provided by all levels, and should occur in the context of preventing the transmission of any infection, such as the annual influenza or the common cold. Responsibilities of the individual and families include:

• Taking precautions to prevent the spread of infection to others if an individual or a family member has symptoms of influenza.

• Being prepared to follow public health guidance that may include limitation of attendance at public gatherings and non-essential travel for several days or weeks.

• Keeping supplies of materials at home, as recommended by authorities, to support essential needs of the household for several days if necessary.

First responders must be prepared to deal with a possible (some say eventual) pandemic, while also protecting themselves and their families.

Most human influenza infections are spread by virus-laden respiratory droplets that are expelled during coughing and sneezing. Therefore, body-substance isolation measures must be adhered to along with health maintanenance and monitoring.

The Center for Disease Control has issued the following recommendations: All patients who present to a health-care setting with fever and respiratory symptoms should be managed according to the CDC’s recommendations for respiratory hygiene and cough etiquette and questioned regarding their recent travel history. It has not yet been determined that avian flu can be spread from person to person. However, due to the potential risks of human to human infection, isolation precautions identical to those recommended for SARS should be implemented for all hospitalized patients diagnosed with or under evaluation for influenza A (H5N1) as follows:

1. Standard Precautions

• Pay careful attention to hand hygiene before and after all patient contact.
• Use gloves and gown for all patient contact.
• Wear when within 3 feet of the patient.
• Place the patient in an airborne isolation room (i.e., monitored negative air pressure in relation to the surrounding area with six to 12 air changes per hour).
• The CDC has recommended that, the minimum requirement is a disposable particulate respirator (e.g. N95, N99 or N100) used in accordance with 29 CFR 1910.134 for respiratory protection programs. Workers must be fit tested for the model and size respirator they wear and must be trained to fit-check for face piece to face seal, when entering the room.
• If transport or movement is necessary, ensure that the patient wears a surgical mask. If a mask cannot be tolerated, apply the most practical measures to contain respiratory secretions
• Additionally, all health care workers, first responders or any emergency personnel that may be exposed should maintain good health and keep up on preventive vaccines.
Avian Flu has not mutated into a human to human form, but the possibility does exist so we must be vigilant in our precautions and keep our knowledge base up to date.
Some web sites that first responders can visit for further information are:

http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm
http://www.osha.gov/dsg/guidance/avian-flu.html
http://www.iafc.org

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