Bar Journal - Spring 2007
Public Health Emergencies and Infectious Diseases Why is Pandemic Influenza Different?
By: José T. Montero, M.D
Microbes live in every conceivable ecological niche on the planet and have inhabited the earth for many hundreds of millions of years. The vast majority of microbes are essential to human, animal and plant life. They are highly adaptable and occasionally a microbe is identified as a pathogen because it causes an acute infectious disease or triggers a pathway to chronic disease, including some cancers.
Infectious diseases continue to be a serious burden in developing and industrialized countries alike. Whether naturally occurring or intentionally inflicted, microbial agents can cause illness, disability or death. They can affect individuals or disrupt entire populations, economies and governments. In our highly interconnected “global village”, one nation’s problem can soon become every nation’s problem as geographical and political boundaries offer trivial impediments to such threats.
Microbial threats emerge, reemerge, and persist. Some microbes cause newly recognized diseases in humans; others are previously know pathogens that are infecting new or larger population groups or spreading into new geographic areas. Within the last ten years, newly discovered infectious diseases have emerged in the United States and several of them made their way up to the New England region (e.g., hantavirus pulmonary syndrome from Sin Nombre virus, with a confirmed case in Vermont). During the same time, there has been a worldwide resurgence of long-recognized infectious diseases (e.g. malaria, cholera, dengue and tuberculosis). The United States has seen the importation of infectious diseases, such as West Nile Virus encephalitis, measles, multidrug-resistant tuberculosis and malaria, from immigrants, from U.S. residents returning from foreign destinations, and via products of international commerce.
The realization of just how quickly newly discovered infectious diseases can spread has heightened appreciation of the inherent dangers of microbial pathogens. Acquired immunodeficiency syndrome (AIDS) has become the fourth-leading cause of death worldwide in a mere 20 years since its discovery. Today, more than 40 million people are living with the infection from the human immunodeficiency virus (HIV), and 20 million people have died from AIDS. In just four years since West Nile virus was discovered in the Western Hemisphere, the virus has spread from its epicenter in New York to the 48 contiguous states infecting thousands and killing hundreds.
The emergence and spread of microbial threats are driven by a complex set of factors, the convergence of which can lead to consequences of disease much greater than any single factor might suggest, as described in the Institute of Medicine Report: “Microbial Threats to Health: Emergence, Detection and Response.” Genetic and biological factors allow microbes to adapt and change, and can make humans more or less susceptible to infections. Changes in the physical environment can impact on the ecology of those animals capable of transmitting an infectious agent as well as those that can act as a host for such infectious agent without getting ill. The changes in the environment can modify the transmissibility of microbes, and the activities of humans that expose them to certain threats. Human behavior, both individual and collective, is perhaps the most complex factor in the emergence of disease. Emergence is especially complicated by social, political, and economic factors – including the development of mega-cities, the disruption of global ecosystems, the expansion of international travel and commerce, and poverty – which ensure that infectious diseases will continue to plague us. Today we also face the threats of intentionally introduced biological agents. The risks to humankind from the willful spread of highly virulent and contagious microbes are considerable, and we in the United States are preparing to defend ourselves with new vaccines, diagnostics, and therapeutics against the many microbes that might be used in a biological attack. We also are cognizant of the need to rebuild public health infrastructure locally and globally as an indispensable means of reacting to such threats.
The general public has a varied level of awareness on the complex mechanisms behind the emergency of infectious diseases threats and the risk that they represent to us as individuals or to the community at large. Today in the US, and especially in NH, infectious diseases are not the main threat to our well-being. A mix of factors including socio-economical situations (high average income, high level of education, and other demographic factors), well-respected public health strategies (availability of universal vaccination for children), general improvements in quality of life (potable water, sewage, general sanitation, food availability, etc) are making the threats of epidemics a remote risk.
In New Hampshire, the Department of Health and Human Services (DHHS) is the entity responsible for developing the programs and implementing the policies and procedures that will keep the threats of infectious diseases at bay. With the exception of Manchester and Nashua (the only cities with full service local health departments), all core public health activities are shouldered by DHHS. There are several statues and rules that govern the day-to-day activities and responses for infectious diseases at DHHS. There is a list of conditions that must be reported to the department because they pose a threat to the public health. Upon report of one of these conditions (infectious diseases and their causative agents), the DHHS communicable disease groups spring into action. These actions may include:
• Communicating with the stricken patient’s health care providers to discuss the diagnosis and treatment approach,
• Contacting the patient to determine the possible source of infection, to discuss communicability, incubation period, need for isolation and whether anyone else may have been infected. Determining who has been exposed and has a high risk of developing the condition is one of the core actions of public health, since finding these potential victims of the condition and providing recommendations for prophylaxis or treatment will prevent further spread of disease.
• Implementing community-based pharmacological and non-pharmacological containment measures. Depending on the condition, this may be limited education on general hygiene; establishing a clinic for distribution of antibiotics to thousands of school students (as was done in the Keene area in response to bacterial meningitis in a school); immunizing thousands of patrons from food establishments (as was done in the Derry area after a possible exposure to hepatitis A); and recommendations for environmental measures that spread across city borders (like those necessary for control of West Nile virus or Eastern Equine Encephalitis virus).
This approach may have been adequate for individual threats or clusters of illness as in the examples cited above. But our world has changed and events can now rapidly overwhelm the limited response capacity of our centralized system. These limitations were evident during the anthrax attacks of 2001 and the resulting community fears around “white powders.” Even though DHHS responded properly, it was clear to us that, for statewide events, our approach and staffing patterns were a great limitation. Because of those events, the Division of Public Health Services developed different policies and plans that would lead to an improved, more sustained response. But it was clear to us that some situations were going to be far beyond even our improved response capacity.
Pandemics — outbreaks of diseases that occur over wide geographic areas (continents, etc)affecting high proportions of the population — are events that will quickly overwhelm our response capacity and require all elements of government and society at large to participate in the response because no single group will be able to respond properly on its own. The media is quick to highlight the occurrence of several infectious diseases and some times our rapid response to them. Our anxious modern society expects a rapid response by the government - actually demands it - and demands an immediate resolution of perceived external health threats, even where there is no need for such a wide response. Recent local examples can be found in the management of incredibly complex individual cases of tuberculosis, vaccine-preventable diseases spreading through sport events, or the threat posed by arboviral illness (such as Eastern Equine Encephalitis). Where the risk occurs across jurisdictions, a different approach is called for. The response is no longer the traditional individual public health interaction to educate and raise awareness of risky behaviors, or encounters with the involved health care providers, sealed with a magical prescription that will resolve the situation and protect us and our loved ones.
Instead, these situations require that we improve the partnerships between the public health departments and the health care system and expand it to a wider public health system, with all community sectors participating, including elected officials, employers, employees, and other community members. This article summarizes the current state of preparedness of the public health sector for an influenza pandemic, response plans, and the successes and difficulties of such planning. The threat of the influenza pandemic requires a stronger public health system and a higher level of participation by each of us in our roles as individuals, family members or as members of corporate entities.
II. The Health Threat
Influenza is a highly infectious viral illness that causes yearly epidemics, which have been reported since at least the early 1500s. An increase in mortality, typically occurring during each epidemic year, is caused by influenza and pneumonia, and/or by exacerbations in underlying cardiopulmonary or other chronic diseases. In the United States, influenza causes as many as 36,000 deaths each year, primarily among the elderly, with an estimated 200 each year in New Hampshire. The virus is transmitted in most cases by droplets, but it can also be transmitted by direct contact. The influenza virus may be present in our respiratory secretions, one to two days before the onset of symptoms, and up to four to five days after the onset of symptoms. The transmission of disease is possible even before we are clinically ill or shortly after we start to feel better. The incubation period is usually two days, but can vary from one to five days. An annual influenza vaccination is the best protection against influenza. Other measures, such as frequent hand washing, the institution of public health measures for universal respiratory hygiene and cough etiquette and staying home while ill (self-isolation) will help stop the spread of influenza in the community, schools or the work place.
There are several influenza virus types, but types A and B, are known to cause most illnesses in humans. A minor change in some viral characteristics (antigenic drift) may result in epidemics, since protection from past exposure to similar viruses is incomplete. A major change (antigenic shift) may result in a worldwide pandemic if the virus, for which humans have no protection, can be efficiently transmitted from person to person.
Influenza viruses are distinctive in their ability to cause sudden, pervasive illness in all age groups on a global scale. Previous pandemics, however, caused disproportionate illness and death in young and previously healthy adults. Also, new data from recent epidemic years show that young children are at increased risk for complications, hospitalizations, and death from influenza. Within the 0- to 4-year-old age group, hospitalization rates are highest among children 0 to 1 year of age and are comparable to rates reported in persons 65 years old and older.
Avian influenza type A viruses (“bird” flu viruses) naturally occur in a wide variety of domestic and wild birds. Cases of avian influenza with low or high severity, based on bird mortality and genetic sequencing, occur periodically in the U.S. Avian influenza strains typically only infect and cause disease in birds (most notably domestic poultry) but several subtypes of avian influenza A have been shown to cause disease in humans.
The H5N1 virus is a highly pathogenic (HP) avian influenza subtype circulating in Southeast Asia since 1997. Outbreaks of this subtype have resulted in the death of millions of domestic and wild birds in Asia, Africa, Europe, the Pacific and the Near East. From January 2003 through March 27, 2007, there were 282 human cases of H5N1 infection reported in association with these outbreaks. One hundred sixty-nine (60 percent) of these reported cases have died. Most of these human cases occurred from direct or close contact with infected poultry or contaminated surfaces. In rare instances, person-to-person spread has been documented but not spread to the general population. Wild bird migration and bird importation serve as possible sources for movement of highly pathogenic H5N1 avian influenza into new regions of the world, including the U.S. and NH. Should H5N1 (or any novel influenza strain) gain the ability to efficiently spread from person-to-person, there is the possibility of a pandemic.
The primary reservoirs for human influenza infections are other humans; however, birds and mammals, such as swine, are likely sources of novel subtypes that may lead to the next pandemic. To date, the most threatening of these novel subtype reservoirs is avian. Recent reports on avian influenza type AH5N1 outbreaks highlight that the potential for efficient person-to-person transmission may be approaching. With the increase in global travel, as well as urbanization and overcrowded conditions, global epidemics due to a novel influenza virus are likely to spread rapidly around the world.
An influenza pandemic is considered to be a high probability event. Given the potential for influenza’s rapid virus transmission and evolution, there may be as little as one to six months’ warning before outbreaks begin in the U.S. Outbreaks of a novel influenza strain would present a unique public health emergency because they are expected to occur simultaneously throughout much of the country and inthe state, hindering the effectiveness of shifts of human and material resources (such as health care personnel and vaccines) that normally occur in most other natural disasters. The impact of the next pandemic could have devastating effects on the health and well being of New Hampshire citizens. Further predicted complications include a delay in production of effective vaccine and potential shortages of vaccine and antiviral agents.
In our state the response to influenza pandemic will be based on the State of New Hampshire Public Health Emergency Preparedness and Response Plan, and therefore will require a similar infrastructure to what is used in other anticipated emergencies, such as a bioterrorism attack. However, a pandemic poses unique challenges in surveillance, vaccine delivery, and administration of antiviral medications, health care delivery and communications that will need specific consideration. These considerations depend on the level of severity of the pandemic. To facilitate the planning process, the World Health Organization and the federal government has developed a scale that breaks down the pandemic into phases and stages.
These classifications were still not discriminating enough for response planning efforts and in February 2007 the Centers for Disease Control and Prevention (CDC) released the Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States—Early, Targeted, Layered Use of Non-pharmaceutical Interventions. This document presents a clever approach to classifying the pandemics using a Pandemic Severity Index (PSI) analog to the well-known system used for hurricanes. The PSI categorizes the severity of the pandemic based on case fatality ratio (the proportion of deaths among clinically ill cases). Pandemics will be assigned to a PSI category with Category 1 being least severe (equivalent to a regular flu season) and Category 5 being the most severe (similar to the 1918 pandemic or worst). The CDC director is the person at the federal level charged with determining category designation.
III. NH PANDEMIC INFLUENZA PLANNING HISTORY
Based on the information presented earlier, it is clear that a pandemic will happen. What is impossible to predict is everything else. We have no certainty about when will it happen, how severe it will be, what population groups will be affected the most, or what countermeasures will be available (antiviral medications, vaccines and other supplies for management of the disease and its complications). But we still need to prepare for it, because when the pandemic reaches the U.S., it will undoubtedly put the citizens of NH at risk. The goal of NH’s Division of Public Health Services (DPHS) in the event of such a pandemic is to minimize the impact of adverse events on the people of the state. The first NH influenza pandemic preparedness plan was completed in 2001 and its latest iteration was published on February 2007. It is available at the DHHS website www.state.nh.us. That plan encompasses various aspects of preparedness, emergency response, and the recovery and maintenance efforts to take place in the event of influenza pandemic, from a public health perspective. It is clear that the response to the pandemic is not solely the responsibility of DHHS; consequently, several other plan components should be developed in the near future by other state agencies and community partners.
Because of these uncertainties, all plans will be continually changing. The science behind any prevention or control measure is continuously evolving, so all recommendations must remain fluid, and within a couple of years, sometimes months, these preventive steps can even become clearly opposed to what is required. Management of uncertainty and dynamic processes is certainly a skill that our leaders and managers must have.
A comprehensive plan for influenza pandemic prevention and control requires defining first the affected population, as well as the expected magnitude of the event, then defining three separate consecutive phases: preparedness, response and recovery. For each stage, actions can be grouped onto four main groups:
• Traditional and enhanced public health activities
• Community-related measures and actions
• Services performed by medical and other social and ancillary providers or agencies
• Countermeasures: vaccines and antiviral medications.
Community Profile and Planning Assumptions
Past pandemics’ illness and death data as well as recent predictions indicate that influenza, while affecting individuals of every age, may more significantly affect certain age groups. Typically, hospitalization rates due to influenza are highest among children 0 to 1 years of age and in persons 65 years of age or older. Using this age group data with statewide hospital data, the estimated maximum morbidity and mortality during an influenza pandemic can be calculated using CDC’s FluSurge2.0 software. It is important to note that these numbers serve only as estimates of potential total impact. They are not indications of how or when individuals will become ill. Attack rates, as well as hospitalization and mortality rates used in the calculations were determined by a consensus of regional medical surge planners at the New England Pandemic Influenza/Avian Influenza Regional Meeting in August 2006.
The development of the DHHS’ current plan is based on the following assumptions:
• A novel influenza virus strain will likely emerge in a country other than the U.S., but could emerge first in the U.S. and possibly in NH.
• The federal government will assume the responsibility of influenza vaccine research, development, and procurement.
• It is highly likely that moderate or severe shortages of vaccine will exist early in the course of the pandemic and also possible that no vaccine will be available.
• The supply of antiviral medications used for prevention and treatment of influenza will be limited and possibly targeted to specific populations.
• The federal and state governments have limited resources allocated for state and local plan implementation, and therefore there is need for supplementary resources in the event of a pandemic, which may include the redirection of personnel and monetary resources.
• The federal government has assumed the responsibility for developing materials and guidelines, including basic communication materials for the general public on influenza, influenza vaccine, and antiviral agents, in various languages; information for health care providers; and training modules. Until these materials are developed, the state has the responsibility to develop such materials for its citizens.
• In the event of an influenza pandemic, the state will have minimal personnel resources available for on-site local assistance; therefore, local authorities and regional planners will be responsible for region-specific pandemic preparedness and response plans, including the modification of this document so that it is region-specific.
• Emergency response, including maintenance of critical services and surge capacity issues, is included in the State Emergency Operations Plan (EOP) Emergency Support Function (ESF) 8, and should not be duplicated in the pandemic planning process.
IV. Traditional and Enhanced
Public Health Activities
Public Health Surveillance
Surveillance for influenza requires global and national monitoring for both virus and disease activity. Influenza viruses are constantly changing and knowledge of which viruses are circulating is needed to make decisions about the annual influenza vaccine. Disease surveillance is required to track the impact of circulating viruses on the human population. The objectives of influenza surveillance are to determine when, where, and which influenza viruses are circulating; to determine the intensity and impact of influenza activity; and to detect the emergence of novel influenza viruses and unusual or severe outbreaks of influenza. Surveillance efforts, particularly in Asia and surrounding countries, have increased dramatically since the emergence of avian influenza A (H5N1).
The CDC coordinates influenza surveillance in the U.S. In NH, influenza is not a reportable disease, but surveillance systems in place routinely will be used during the pandemic preparedness phase to help determine the extent of illness and current circulating influenza virus subtypes. Furthermore, expanded surveillance systems have been developed to enhance the state’s capacity for early detection, allowing us to respond and implement containment measures during a pandemic. Expanded surveillance systems are also in place.
Data collection should focus on individual cases in the early stages of a pandemic and shift to aggregate data collection as the pandemic evolves. During a pandemic the management of these systems is a priority and even in the face of high absenteeism rates, properly trained personnel will have to manage them, posing a planning challenge for just on time training and redirection of personnel with data management expertise
Surveillance Preparedness Activities
The Division of Public Health Services (DPHS) routinely provides recommendations to health care facilities, health care providers, and the general public regarding the prevention and control of influenza. In the early stages of a pandemic, the DPHS staff will be responsible for investigations of initial cases. These investigations, based on previous experiences when SARS was the threat, proved this to be a highly demanding and sometimes overwhelming task. DHHS capacity is quite limited, making necessary the establishment of priority criteria for deciding what diseases will not be investigated, what other functions will be postponed, regulations that may need to be relaxed, and how to redirect resources toward performing selected essential functions. This task can only be accomplished when comprehensive Continuity of Operations plans (COOP) are developed. DHHS has already developed its COOP, but every single organization, private or public, should have one as well.
Health care providers are responsible for maintaining strict infection control practices in their offices and facilities to help limit the spread of infectious diseases. Offices and facilities are encouraged by DHHS to display mask and hand hygiene posters in prominent locations in offices or facilities.
The state’s Public Health Laboratories (PHL) plays an integral role in influenza surveillance. They should be able to perform influenza testing, type/subtype influenza culture isolates, and send unusual isolates to the CDC for further characterization. The PHL provides influenza testing free of charge to health care providers in facilities such as hospitals, long-term care facilities, or schools reporting outbreaks of influenza-like illness (ILI) or unusual cases of ILI. The PHL has a contingency plan for laboratory surge capacity, to ensure there is sufficient staff trained for influenza testing and cross-trained for continued laboratory operations. The surge plan includes making agreements with private laboratories in the state to assist with testing in the event that the PHL is overwhelmed by testing demands during an influenza pandemic.
Risk Communication and Public Education
The purpose of public education and risk communication is to ensure a timely, accurate and continual flow of information to the public and the media about a public health emergency. Communications will be in keeping with the principles of Crisis and Emergency Risk Communication whenever possible in order to keep the public informed. Both State Public Information Offices (PIO) and regional planners on the local level will be involved in communication strategies.
Because of anticipated shortages and delays in receiving vaccine and antivirals, messages informing citizens about the rationale for priority groups, as well as measures to be taken until such agents are available, will be critical. The public will likely encounter some unreliable and possibly false information in the media, underscoring the need for accurate, consistent and timely communication messages from NH DHHS/DPHS. Mechanisms for communication with the public will vary depending on the phase of the pandemic and its impact on New Hampshire communities and in neighboring states.
During an influenza pandemic, populations with particular needs may require targeted messages and particular services to ensure the protection of their health. Such special needs populations may include: children, the blind or visually impaired, and the frail and elderly.
Each organization serving these groups is responsible for creating its own emergency preparedness, response, and recovery plans. Regulated populations (such as long-term care facilities, childcare centers, correctional facilities, etc.) must develop their own plans.
Command and Control
The sustained, coordinated efforts required to control pandemic influenza lend themselves to the principles and structure of incident command and management systems. Establishment of this command for a statewide response is a responsibility of the Homeland Security and Emergency Management (HSEM) director at the Department of Safety. The HSEM will then activate the NH Emergency Operations Plan (EOP), which outlines the responsibilities of organizations and state agencies that would likely be involved in an emergency situation. At the heart of the EOP are 16 Emergency Support Functions (ESFs). One or more of these ESFs might be activated in the event of an influenza pandemic. Each ESF is headed by one primary agency, with one or more support agencies assigned to the ESF to help with operations. NH DHHS is the primary agency for ESF-8, Health and Medical Services, and plays a support role in seven other ESFs. The State Emergency Operations Plan can be found on the Internet at http://www.nhoem.state.nh.us/Planning/contents.shtm.
When applicable, the NH DHHS Commissioner will recommend that HSEM activate the State of NH Emergency Operations Center (EOC), which will coordinate the incident response, utilizing the NH EOP described above. In the case of an influenza pandemic, the NH DHHS will act as the lead State agency, which may place the State Epidemiologist in the position of incident commander. Overall, during an influenza pandemic, the goal will be to reduce influenza-related morbidity and mortality and keep social disruption and economic loss at a minimum. To meet this goal, priorities are to maximize the use of limited resources, monitor the status of the outbreak, collect and organize situational information, manage staffing needs and requirements, monitor/supply persons in isolation and quarantine, maintain an inventory of respirators and other personal protective equipment (PPE), track the status of and procure essential supplies, operate special/temporary facilities, and manage administrative and financial aspects of the response.
Community Preparedness Activities
Current mathematical modeling suggests a combination of pharmaceutical and non-pharmaceutical interventions will slow the spread of illness, thereby allowing for a more manageable response to overwhelmed healthcare institutions, workplace absenteeism, etc. To implement either type of intervention, the general public must be aware ahead of time that these intervention options exist, and they must be provided with the educational tools to prepare themselves, their families, and their workplaces. Therefore, a critical role for planners is to effectively communicate community-wide preparedness activities to their communities and various stakeholders and planning partners. During the preparedness phases we need to consider and make contingencies for the societal impact of each one of the suggested interventions listed below. Impacts may be economical, legal, ethical, logistical, and/or psychological. Some of these interventions, such as quarantine, may only be applicable at the very early stages of a pandemic.
The decision to institute community containment measures, and the nature and scope of these measures, will primarily be based on the CDC determination of Pandemic Severity Index, but may also be based on the following factors: number of cases, characteristics of disease transmission (i.e., incidence rate, number of generations), types of exposure categories (i.e., travel-related, close contact, health care personnel, unlinked transmission), morbidity and mortality rates, community compliance, and the availability of local health care and public health resources. Further considerations are the expected benefit of the intervention, the feasibility of successful implementation, direct and indirect costs, and the potential consequences of the event on critical infrastructure, health care delivery and society.
Though some interventions are individual in nature, they may affect communities by calling for support or influencing disease transmission in community settings. The decision to implement these interventions will be made by a variety of individuals, and may include the Governor, State Commissioners, and other officials. These individuals may also assign a designee as appropriate. Who authorizes these decisions is dependent on current NH state law.
Non-pharmaceutical interventions are based on the concept of “social distancing,” and are usually targeted to either specific groups of individuals or to an entire community. Social distancing implies reducing contact with other people, reducing the risk of influenza transmission. Suggested interventions for which communities should prepare include the following:
• Quarantine. Though quarantine of exposed, at-risk persons may not be effective as the pandemic progresses, in early phases it may be appropriate. Examples include when individuals are exposed to an influenza case at a group gathering, in a closed vehicle, or at their workplace. Isolation will also occur during the pandemic, where individuals who have influenza are physically separated from those persons who are not ill. Both isolation and quarantine are discussed in further detail in a separate article in this journal. (See page 46)
The factors associated with isolating and quarantining individuals that should be considered in the preparedness phase are:
• Support of individuals in isolation and/or quarantine; working through the logistics of providing them with basic daily living needs.
• Reducing stigmatization and psychological impact.
• Development of appropriate sick leave policies. In pre-pandemic stages, employers and human resources managers should develop policies that encourage employees to use their sick time properly and discourage “presenteism”, when sick people show up to work regardless of how infectious they are. Sick employees may not realize that they pose a risk to their co-workers and managers may not be aware that one sick infectious employee exposes several others and by that productivity may be affected in a bigger scale that if the initial employee was allowed to stay home while sick.
• Mask and facial covering recommendations may differ depending on the extent of potential exposure.
• Health Care Personnel (HCPs). At this time, the recommendation states that N-95 respirators (which are individually fitted masks that filter particles less than 5ìm in size 95 percent of the time) be used by HCPs during procedures that may generate aerosols and during direct patient care activities; N-95 respirators are also recommended for use by HCP support staff that has direct contact with pandemic influenza patients.
• General Public. There is currently no recommendation for public stockpile of N-95 respirators. At this time, there is insufficient evidence to support well persons wearing masks in public settings, and this is not a recommended measure. However, the general public should maintain an appropriate social distance of greater than three feet when near persons ill with influenza. Well individuals may choose to wear masks, but community use should not interfere with the supply for health care sites.
• Pandemic Influenza Cases. Surgical masks or other facial coverings may be appropriate when worn by clinically ill individuals who remain in the home or cannot immediately be removed from contact with others, or when they are traveling to access health care services.
• Snow days. The term “snow days” refers to days when a significant portion of the population is asked to stay at home, as if there were a major snowstorm. Employers and others should identify mission-critical personnel who are essential to maintaining societal infrastructure (i.e., gas, water, electricity).
• Self-shielding. This is a self-imposed measure where individuals stay at home so as to exclude themselves from infected persons. Communities should prepare for the fact that many individuals will choose to self-shield. Self-shielding differs from voluntary quarantine in that it is entirely self-imposed with no prompting from public officials.
• Restricted access and/or cancellation or closure. These interventions may include the following:
• Restricted access or closure of specific buildings, such as public swimming pools and gyms
• Cancellation of public events, such as sporting events, movie theaters, concerts
• Closure of public buildings
• Closure of private buildings. Closure of malls and offices, will be contingent on that entity’s own continuity of operations planning.
• Closing of schools and day cares for the duration of the pandemic. This measure, that in the different models has one of the highest benefit yields, may be the one with the higher level of social impact. Who will take care of the children while we are at work? Can we keep them at home (especially teenagers) and out of the malls or other settings where people gather? How can we provide food to the low-income children that are in the breakfast and lunch programs? Can we or should we attempt to continue education through other means? Most of these questions are in the process of been answered under the guidance of the Department of Education. The state already has conducted a successful tabletop exercise where some of these issues were explored.
Currently there is no vaccine because we do not know what exact virus will cause the pandemic. There are some vaccines already developed against the H5 N1 strain undergoing testing. Expectations in the scientific community are that those vaccines may offer some cross-protection if a virus of this family causes the pandemic. However, there are several technical difficulties that need to be resolved: high doses administered on multiple occasions are required to provide protection. These requirements will severely strain an already inadequate vaccine production system. For a strain specific vaccine, production will require four to six months from the time the pandemic vaccine strain is identified. Whether pandemic vaccine becomes available during or after the first wave of illness will depend on where the pandemic begins, how soon it is detected, the efficiency of spread, and the impact of containment measures. Once production has begun, the vaccine will likely be manufactured at a steady rate. The number of vaccine doses that will be manufactured each month will be a function of both manufacturing capacity and of the amount of antigen required per dose of vaccine. The planning assumption recommended by CDC is a manufacturing capacity of 50.4 million courses per year, or 4.2 million courses per month. If we extrapolate this numbers to NH it means that will be able to vaccinate 1.5 percent of its population with 2 doses per month (Source: Pandemic Influenza Vaccination: A Guide for State, Local, Territorial, and Tribal Planners. CDC. December 11, 2006).
A critical task in a pandemic preparedness is development of a priority list for limited supplies, such as vaccines, antiviral medications or those who will have access to medical care. This task has enormous ethical implications that cannot be managed based on our own fears, or on the natural human instinct to protect our loved ones. The recommendations should be based in clear goals that will differ depending on the level of supply and the severity of the event. It will be easier to prioritize the allocation of a moderate or scarce supply of medications in a mild pandemic that predominantly affects one age group. However, if the pandemic is severe (Category 5) and resources are scarce, a completely different approach will be needed. It may require that we do not prioritize groups who may be most likely to be sick or die, but those people working to fight the pandemic and provide care as well as those providing essential community services.
The CDC is expected to provide working guidance before the pandemic. It has already put in motion a complex process for developing the recommendations that includes ethics committees, community focus groups and disease and emergency response experts. So far they are working on an approach that will follow a layered approach involving four groups:
• Homeland and national security (deployed forces, support forces, National Guard and border security personnel)
• Health care and social services groups (personnel in public health, inpatient facilities, outpatient sites, home health, long term care staff, and social services agencies)
• Critical infrastructure services (police, EMS, fire, electricity, water, communications, transportation, oil and gas, chemical, food and agriculture, banking and finance, government, others)
• General population (pregnant women, children, high risk by disease, elderly, those who can not be vaccinated, general public)
Any categorization of priority groups will certainly generate discussion, accusations of unfairness and even maneuvers and posturing by some to get particular groups moved to a higher priority level. We all need to accept that this is dynamic process that will keep changing based on what we learn about the pandemic and the availability of supplies. Nobody should consider that they have the right to have access to limited supplies.
Another key task for state agencies and their regional partners is to develop distribution systems for the vaccines, including selecting sites that can be used as mass vaccination clinics if the resources are available, or well-protected and secure sites to vaccinate those who are selected based on the priority lists. A key factor to consider as well is the availability of trained individuals to administer the vaccines.
Under the current pre-pandemic status there is no certainty on what strain of the influenza virus will cause the pandemic. The strains currently involved in the avian flu outbreaks occurring in Asia, Africa and Europe are resistant to some antiviral medication and susceptible to others. If these same strains evolve and cause the pandemic, we can expect a similar pattern of response to medications. This will leave us with two antiviral medications currently approved for prophylaxis and treatment of influenza: tamiflu® and relenza®. There are no guarantees, though, that the virus will not evolve to become resistant to these medications as well. That is the reason there are several ongoing antiviral resistance surveillance projects as well as research into new medications.
The antiviral medications face similar planning issues as the one stated earlier for vaccines. Current supplies are quite limited and the national goal of stockpiling treatment for 25 percent of the populations is still at least one year away. There are some promising changes such as the development of added capacity for production of antivirals in the US. This will allow us as a nation to have a steady production of 6 million treatments per month at the time of the pandemic.
The use of antiviral medications should follow the standard medical approach and should be used primarily to treat cases. This approach has proven effective for seasonal influenza, meets the expectations of the public and it is considered the most efficient use of limited supply.
Several of the mathematical models used to determine the value of several possible measures to be implemented during a pandemic clearly suggest the value of household post-exposure prophylaxis. A major caveat of this approach is that it requires that antiviral medications be given within 24 hours of exposure, or within 24 hours of illness onset for those who are ill. Since there are not enough supplies to provide the medications to all of those who believe or do really need the medication, a controlled distribution system will need to be in place. To further complicate this situation, most cases are expected to start as any other regular viral infection: fever, malaise, etc. How can we know who has an infection with pandemic strain, and who has any other kind of cold? Assuming that we have an appropriate test available, we can test people before they are granted access to the medication. This approach requires the development of a new testing strategy. If a test is not available: how can we select who will get antivirals and who will not? How can we be certain that somebody is not feigning symptoms in order to get access to antiviral medications? Can or should the state write strict medical guidelines mandating the prescription only to selected or state-authorized patients? Does this approach infringe the medical independence and right to practice? Is there any way of enforcing it? What will be the consequences?
Another component of the antiviral medication strategy has to do with prophylaxis of selected populations by reason of occupation, location or special health risk.
• Health-care workers: can we ethically ask a person to treat somebody with the pandemic influenza without offering them the best protection available?
• Critical services: Police, fire and critical infrastructure workers. Because such public safety and other infrastructure workers do not have as high a risk of exposure as other groups, some models indicate that if supplies are scarce, this may not be the right group to target if the objective is to decrease the spread of cases. But, because of their function and role in maintaining society, the conditions of a severe pandemic (category 4 or 5), will merit a different consideration.
• Severely immune-compromised patients.
• Person in closed settings: prisons, etc.
• Families of health care workers or critical services workers.
Providing prophylaxis to groups chosen because of critical services needs may create an inaccurate perception of protection or lead to a misrepresentation of the real protection that can be achieved with antiviral medications. There is no expectation to have supplies available to provide medications for the complete duration of the pandemic to any group, not even for health care workers who are dealing with the most infectious cases and because of that have the highest level of risk. The questions that follow for people in the critical services category are: when should I use my one-time allocation of antiviral medication? What happens after I used it?
There is not a simple answer for any of these questions. Although the budget currently under discussion at the New Hampshire Legislature includes appropriations to buy antiviral medications beyond the recommended stockpile levels, there will be the perception, for some, that it will be too much or it will not be enough. The questions about how much money can or should we put toward this effort, in the face of many other important public health needs, as well as those about allocation of scarce resources have important policy, political and ethical considerations. The division of Public Health Services has been working for the last couple of years with an ad-hoc ethics committee to help us explore this difficult field. The federal government called a panel of experts in bio-ethics and is circulating a draft document called Ethical Guidelines in Pandemic Influenza. The NH legislature is currently discussing legislation that includes the creation of a formal ethics advisory board.
New Hampshire hospitals have 2,149 staffed non-ICU beds (Intensive care unit) and 374-staffed ICU beds. In a severe pandemic we estimate that we will see 2,333 inpatients admissions related to flu, at the peak of the pandemic, with close to 500 new daily admissions. These numbers show a sober panoramic of our hospital capacity and what will need to be done in times of a crises. Every hospital across the state has well-designed evacuation and surge plans that work quite well under several scenarios, except pandemic. Since everybody will be affected at the same time, there is no possibility for sharing resources.
To complicate things more, already overtaxed personnel in the health care sector will be getting sick, or staying home to take care of sick relatives, or even refusing to work for fear of increased exposure. The only modern event that can be used as a reference is the SARS epidemic of 2004. In Toronto, more than 10,000 health care workers were quarantined or isolated, but there was no generalized panic or refusal to come to work. We can only hope for the same response from our workforce.
The “NH Medical Surge Guideline” and the “NH Hospital Surge Capacity and Capability Plan” are the documents that describe the models adopted to manage increases in demand on our medical system, medical surge capacity and capability. They provide specific guidance for medical surge planning in New Hampshire. The intent is to be prepared for emergencies that generate victims requiring medical treatment that surpass the normal resource capacity and/or capabilities of NH communities.
The state adopted as a model a “Modular Emergency Medical System” (MEMS). This is a conceptual framework for managing a surge in patients requiring triage, prophylaxis or inpatient care. It includes neighborhood emergency centers and acute care centers. These two functional components are not necessarily operating in our traditional health care facilities, certainly not in the hospitals that they are trying to augment.
An acute care center (ACC) is a facility established to provide medical care in a community-based location. ACCs are community-based healthcare surge facilities that provide limited care to patients that would normally require admission to an acute care hospital. ACCs are ideally located in buildings of opportunity in close proximity to an acute care hospital. ACCs will not manage critical care patients, such as victims requiring artificial ventilation.
The Neighborhood Emergency Help Center (NEHC) is intended to:
• Function as a high volume point of dispensing (POD) for prophylactic medication
• Self-help information
• Instruction (e.g., home care, medical follow-up)
• Triage large numbers of people seeking care, especially to identify those that require inpatient care and to ensure that they are stabilized for evacuation to either an ACC or hospital, depending on the patient’s level of acuity.
Neither the ACC nor the NECH exist today. They need to be developed, equipped and staffed as part of an implementation strategy in the years to come. The state has provided specific recommendations to the regional planners for the development of possible locations and initial planning. It is expected that for a pandemic situation they will provide approximately 1,500 hundred beds distributed in strategic locations around the state, with the exact amount of beds per region based on the population that they serve. Several questions about their feasibility because of financial support, logistics, medical responsibility, general support systems (laundry, food, transportation, etc), still remain.
A daunting question superseding the implementation of the medical surge strategy has to do with human resources. Today, we do not have enough human resources. There is a national shortage of nurses and in some areas there are not enough physicians. How can we provide those resources during a pandemic? Working assumptions will call for modification of standards of care and standards of practice. There is a clear need to define what kind of medical services or procedures can be postponed until after the pandemic. Clear risk-communication strategies need to be implemented so that messages can be brought to the general public and practitioners. The responsibility of health care providers will be to protect the public’s health by adhering to principles/protocols and or priorities developed for a pandemic situation. Patient care must be provided within the context and limitations of those altered standards.
Still we can expect that several individuals will consider their pain and/or suffering a bigger issue that those of others and possible legal actions will be brought. Why did that person and not my child get the only ventilator? Why was that lady admitted to the hospital and not my mother? You postponed my arthroscopy and now I have a permanent disability, etc. These are questions that will surface during this kind of crisis. As a society, we need to be prepared to understand the core issues and to deal with all the nuances generated when the implementation of such policies becomes a need.
Mass Fatality Management
The projections used by DHHS for the most likely scenario assume 3,930 deaths in New Hampshire over an eight-week period. This will overwhelm the system that deals with fatality management. Temporary internment, postponing of religious services and financial issues faced by families with multiple casualties are things that need to be addressed. A plan to deal with this component of the pandemic is under development.
The development and implementation of a pandemic preparedness and prevention plan of this magnitude requires local and regional participation. DHHS developed strategy of regional planning groups called “All Health Hazard Regions (AHHR)”. These groups are tasked with taking the templates developed by DPHS and adapting them to the state regional realities and resources. They are filling in the blanks of who will be actually performing the functions, actions and activities that are required to really protect the health of the public while managing an emergency of this magnitude.
Employment polices, sick time policies, continuity of operations for private business and every local, regional or state agency and the social impact of the social distancing policies presented earlier are some of the areas for which plans need to be developed. The core structure has been laid out by DHHS with the support of other state agencies and stakeholders. But a really comprehensive pandemic preparedness and control plan, where we agree on goals, objectives and accepted outcomes will not exist unless all of us as in our multiple roles as individuals or corporate citizens stand up and do our part. Please read the public health plan as it pertains to your own needs, start with an emergency plan for your family, for yourself. Then as an employee or employer look at how the pandemic may affect you. Contact your professional or trade association; see where you fit and what needs to be done. Contact your regional planners. You will find a map with the all health hazard planning regions in our website (www.state.nh.us), give them a call and get yourself involved. It is the right thing to do.