Colin Kopes-Kerr, MD
5989 Vista Ridge
Santa Rosa CA 95409
E-mail: cpkerr@nni.com
Kopes-eticHealth.com:
A New Dawn for Health Care Information
WHAT'S HAPPENING NOW?
What You Need to Know About Avian Flu
PREPARING FOR THE NEXT PANDEMIC: HOW BAD
WILL IT BE? [March 2006]
Most of us suppose, given how powerful that modern medicine
that somehow it won't be that bad, that technology will some how brush it aside
or beat it back. This is pretty naive thinking. The truth that readers of this
newsletter should be very aware of is how broken and fundamentally irrational
the US medical system is. Broken, irrational systems do not mount very effective
responses to crises (witness the Katrina fiasco). In fact, as the US system has
so well demonstrated in its inveterate resistance to public health measures and
general prevention, it likes a crisis. Some (many) corporations benefit
enormously at the time of crisis (and will again); and, of course, these
entities are very well represented to our politicians by Jack Abramoff and
others.
I am going to suggest that we sit down for a moment (and it
would definitely be better to be sitting when your review what follows) and
reflect on what a new pandemic, a la the pandemic of 1918, would mean. These
concerns come from Michael Osterhold, PhD, MPH, via Oprah and the New England
Journal of Medicine.
The Baseline: During a typical year in the US, 30,000
to 50,000 persons die as a result of influenza virus. The global death toll is
about 20 to 30 times higher. "We usually accept this outcome as a part of the
cycle of life." Currently the fragmented and limited production capacity of our
1950s egg-based technology for producing influenza vaccine and the lack of a
national commitment to universal annual influenza vaccination mean that
influenza epidemics will continue to present a substantial public health
challenge for the foreseeable future.
The Inevitable: Influenza experts recognize the
inevitability of another pandemic. Will it be caused by H5N1, the avian
influenza virus strain currently circulating in Asia? Nobody knows. What should
we do in the face of uncertainty?
Certainly, if it happens, given the marvels of modern transportation, it will
spread worldwide at once. No one can be expected to be protected from exposure.
How to Prepare:
1. Ramp up vaccine production research. Egg-based technology
is slow and can never meet the projected demands. It takes 350 million chicken
eggs and 6 months to make the 300 million doses of influenza vaccine needed
worldwide annually for routine needs. We have an urgent need for research to
develop and perfect cell-culture-based vaccine production. If a pandemic were to
develop, production of vaccine with current technology will take 6 months to
develop and produce. Given the capacity of all the current international vaccine
manufacturers, supplies during the next 6 months would be less than a billion
monovalent doses; two doses may be required for protection. Vaccine production,
however, only has a major role in our response if we have the luxury of a year's
lead-time. "The current system of producing and distributing influenza vaccine
is broken, both technically and financially. The belief that we can greatly
advance manufacturing technology and expand capacity in the normal course of
increasing our annual vaccination coverage is flawed. At our current pace, it
will take generations for meaningful advances to be made...We need an
international approach to public funding that will pay for the excess production
capacity required during a pandemic."
2. We need to learn something about and practice real public
health. The mere drafting of white papers and general plans is not worth much.
"We need a detailed operational blueprint of the best way to get through 12 to
24 months of a pandemic...If we translate the rate of death associated with the
1918 influenza virus to that in the current population, there could be 1.7
million deaths in the United States and 180 million to 360 million deaths
globally. We have an extremely limited armamentarium with which to handle
millions of cases of ARDS--one not much different from that available to the
front-line medical corps in 1918."
Consider just a few of the logistical problems that will
emerge right away: "Owing to our global 'just-in-time delivery' economy, we
would have no surge capacity for health care, food supplies, and many other
products and services. For example, in the United States today, we have only
105,000 mechanical ventilators, 75,000 to 80,000 of which are in use at any
given time for everyday medical care; during a garden-variety influenza season,
more than 100,000 are required. In a pandemic, most patients with influenza who
needed ventilation would not have access to it.
"We have no detailed plans for staffing the temporary
hospitals that would have to be set up in high-school gymnasiums and community
centers--and that might need to remain in operation for one or two years. Health
care workers would become ill and die at rates similar to, or even higher than,
those in the general public. Judging by our experience with the severe acute
respiratory syndrome (SARS), some health care workers would not show up for
duty. How would communities train and use volunteers?...
"Health care delivery systems and managed-care organization
haves done little planning for such a scenario. Who, for instance, would receive
the extremely limited antiviral agents that will be available? We need to
develop a national, and even an international, consensus on the priorities for
the use of antiviral drugs well before the pandemic begins. In addition, we have
no way of urgently increasing production of critical items such as antiviral
drugs, masks for respiratory protection, or antibiotics for the treatment of
secondary bacterial infections. Even under today's relatively stable operating
conditions, eight different anti-infective agents are in short supply because of
manufacturing problems. Nor do we have detailed plans for handling the massive
number of dead bodies that would soon exceed our ability to cope with
them...Urgent planning efforts are required to ensure that we have the syringes
and other essential equipment, as well as the workforce, for effective delivery.
Finally, a detailed plan for vaccine allocation will be needed--before the
crisis, not during it."
3. Communication: Health professionals must become
much more proficient in 'risk communication,' so that they can effectively
provide the facts and acknowledge the unknowns to a frightened population.
4. Contingency Planning: Every responsible adult
should be pondering, Could it happen? and What would I do? There is virtually
nothing on an individual level that can be done. It is also reasonably clear
that our political leaders will only respond if we complain loudly and at the
voting booth. By time there are dead children's bodies piling up (i.e., the
usual kind of stimulus that elicits a governmental crisis response), it will be
far too late. "Planning for a pandemic must be on the agenda of every public
health agency, school board, manufacturing plant, investment firm, mortuary,
state legislature, and food distributor...Is there anything we can do to avoid
this course? The answer is a qualified yes that depends on how everyone, from
world leaders to local elected officials, decide to respond. We need bold and
timely leadership at the highest levels of the governments in the developed
world; these governments must recognize the economic, security, and health
threats posed by the next influenza pandemic and invest accordingly. The
resources needed must be considered in the light of the eventual costs of
failing to invest in such an effort. The loss of human life even in a mild
pandemic will be devastating, and the cost of a world economy in shambles for
several years can only be imagined."
COMMENT: Is it time for us as ordinary, front-line physicians to start thinking
about this potential doomsday scenario? I certainly hadn't given it much
thought. I assumed that the tabloids and Time magazine were just playing the
subject for sales. My wife caught an interview with the author of this piece on
Oprah and reported to me the details, and my first response was to say the guy
must be crazy or just hawking some book on a national tour. So I checked the
Oprah web site to identify him, checked his credentials (he is the director of
the Center for Infectious Disease Research and Policy, and the associate
director of the National Center for Food Protection and Defense, as well as a
professor of public health at the University of Minnesota). He is not selling
any book. The domino effect that will occur with respect to the failure of
ordinary medical care systems once the pandemic start is quite obvious to anyone
who reflects on it. Only a person in total denial of the science of virology
could be unconcerned. The question is not "if" another global pandemic occurs,
but only "when." The certainty is that it will occur, and al- most equally
certain is the fact that we will not be ready. The scenario raises some
interesting questions: Would you show up to work if the pandemic arrived? If you
do, what will you do? Are you expecting to have any treatment to offer, or just
advice? Is there any reason not to offer the advice now?
I assume that most of the readers of this newsletter are already aware that our
current medical system is quite broken. The American public, both at large and
the physicians among them, are quite used to people dying just because they are
poor, or have no access to medicines, specialists, or procedures or even just to
basic nutritional requirements. The prevailing ethic is that this is OK as long
as most of us can opt out. What will be interesting in the pandemic situation is
that no one will be able to opt out. No amount of money, importance, or ability
to travel will remove anyone from risk. There will be no medicine to take. (Tamiflu
having been only partially effective and long since used up). The usual detached
indifference with which those with power and money avoid doing anything about
our continual health crisis will be in short supply. They will get avian flu
just like the rest of us, and 5-10% of them, just like the rest of us, will die.
Only the corporations are immortal. The 'system' of our usual healthcare
delivery, being irrelevant to the calamity, will likely die too. Not at all a
bad thing. Those who survive may have a whole different perspective on what the
social obligation to provide reasonable care for all. A new system might even be
fun to work in.
What is particularly interesting about this impending dilemma
is that the only way out for the rich and powerful is to plan ahead and put up
money and resources for implementation. Most of them, however, are still
reveling in their denial. The real service we could do for this country as
primary care physicians would be to wake them up. A pandemic will come. (Osterhold
MT. Preparing for the next pandemic. N Engl J Med 2006; 352: 1839-42)
A PRIMER ON AVIAN FLU (H5N1): A PERFECT STORM
WHY AVIAN FLU MAY BE THE MOST IMPORTANT MEDICAL ISSUE IN YOUR CAREER:
We all see influenza illness every year, with great
regularity, and variable severity. What's the big deal with this new flu? The
American public, our patients, accept that every winter, millions of Americans,
get the flu; most are home for a week or two, sick and miserable, and then
recover. A few unlucky ones, mostly the elderly, die. The average number of
flu-related deaths in the US is estimated around 35,000. Public health data
suggest that we vaccinate about two-thirds of our elderly each year and much
smaller fractions of other high-risk groups. Only Canada vaccinates a higher
percentage of its population. As the author of this very thoughtful and
provoking review of the subject says, “Flu is a perfect paradigm of the
high-hazard low-outrage risk–the sort of risk that kills people but doesn't much
upset them.”
So why should H5N1 be any different? Since 1997, H5N1 has
spread throughout Southeast Asia's bird population. It has already killed
millions of chickens, and efforts to control it have exterminated millions more.
About 92 persons so far are known to have caught H5N1 directly from birds. Some
9 of them may have caught it from other humans, but this is not yet clear. Yet
this mere possibility has viral researchers and public health officials more
alarmed than at anytime since the great Spanish flu pandemic of 1918.
Since this is a new virus, there is no natural immunity to
it, or even cross-immunity from prior flu infections. H5N1 is particularly
virulent. It seems to kill up to 70% of the people who catch it. The mortality
from common winter flu is less than 1%. Once efficient human-to-human
transmission is established, it will spread around the world in a tidal wave
very analogous to the recent tsunami. As we look back at the newsreel footage of
the results of our unpreparedness for the tsunami and even Hurricane Katrina
(which we certainly knew was coming), we see the disastrous results of
ill-preparedness. So it is worth asking, “Are we prepared to deal with an H5N1
epidemic?” The only honest answer, despite what the politicians are busily
saying, is, “No.”
The WHO (Dr. Klaus Stohr) estimates (guesses) that the H5N1
attack rate would be between 25% and 30%, which has been rounded to “a third,”
and estimates that 1% of those who get ill might die. In the 1918 epidemic 2.6%
of all infected persons died. If you do the math, this means that there will be
18.6 million deaths. A CDC expert (Dr. Martin Meltzer) using a calculator
(available on the web at www.pandemicflu.gov/) predicts 2 to 7 million deaths
(cited on the web at
www.who.int/csr/disease/influenza/pandemic/en/). Although
health care has improved modestly since 1918, epidemiological models from the
CDC project that a modern pandemic will result in 2 to 7.4 million deaths
globally. The gloomier experts , the US expert Dr. Michael Osterholm (who
estimated a 50% attack rate and a 5% fatality rate) and the Russian expert, Dr
Dmitri Lvov project an upper bound of 177 million deaths and one billion,
respectively. And these experts are all quite nervous about the possibilities,
and they are worried about what to tell the rest of us. They don't want to panic
us, but inadequate concern may be just as deadly.
If a pandemic comes, what do we do? First, you have to
realize that there will be no vaccine against it. While some preliminary testing
of potential vaccines is in progress, none are proven effective and none has or
will be produced in quantity. The huge risk for vaccine manufacturers in this
is, if they commit to making hundreds of millions of doses, which is what will
be needed, they risk being stuck with a lot of unused inventory should they not
have accurately matched the vaccine to the prevalent epidemic strain of H5N1.
Therefore, private industry will not do this. It will be left up to the
government, which has done nothing but preliminary testing as yet and some
jaw-boning aimed at drug companies. Even after we find a vaccine that actually
works in trials, then we are at least 6 months away from having an adequate
stock (if we are lucky and there are none of the frequent, recent manufacturing
glitches). Thus, when the pandemic arrives, we will be defenseless for at least
6 months. Many people will die in that time. No one knows whether Tamiflu will
help against this disease; what is reasonably certain is that all of the
minuscule available supply will have been commandeered by that time.
The CDC Director, Dr. Julie Gerberding, testified to Congress
that several hundred thousand treatment courses of one antiviral drug have been
acquired for our US national stockpile. Another CDC expert, however, estimated
that 16 million health care workers and public safety officers would need 93
million courses of antivirals–8 weeks worth for each of them–as protection
against flu during the start of a pandemic. Do not look to medications or
pharmaceuticals of any kind to get you through the pandemic.
So if we are not going to have any drugs or vaccines either to take or to give
to patients, what on earth will we do when this thing hits? This is what is very
important to think about. Then make some specific plans. There are (many) things
to do.
1. Local planning is vital. Virtually all meaningful emergency planning
has to be local. You can't wait for Washington or the state Capitol. (These
folks are going be deeply mired in ineffective Hurricane Katrina-like activity.)
How is your community going to handle education when the schools are closed? All
places of public gathering will be closed. All transportation hubs will be
restricted. How will local essential services be staffed when some people are
out sick and others are frightened to come to work? Identify the essential
workers: hospital janitorial, kitchen, laundry, medical personnel; sewage and
sanitation workers; morticians; power and water plant operations; food producers
and distributors; police, firefighters, and military personnel; telephone system
workers. Most individuals will be out of work for the duration. How will they
cope?
2. Basic Hygiene promotion: Hand-washing, covering your mouth when you
cough, wearing face masks will be the quintessential tools against the spread of
flu.
3. Supplies: Given that most business will shut down, plan ahead for
enough basic supplies to manage in your home with minimal outside contacts.
4. It is time to Alarm People Now: This is the only way they will
have a chance to prepare. Tell them the truth: How bad will it be? No one knows,
but it will be bad. Will medicines be available to help? Not for 6-9 months. Are
there steps to take? Emphasize how much there is to do that is feasible and
practical.
5. Do not cater to the delusion that any form of medicine, vaccine,
technology, or public health measure can stop a pandemic from reaching our
shores and our communities. A pandemic is a pandemic. It will come.
6. Urge citizens to press their leaders for formal planning and resource
allocations. Don't let the politicians avoid this issue, minimize it, or
deceive the public into thinking we have it all under control. By definition, a
pandemic is not under control. It will run its course.
7. Deal with the psychological issues: People will react emotionally to
an awareness of the real risks of a pandemic. The stages of adjusting to a new
and serious risk are well-known. The first stage is some mix of apathy and
denial (where most politicians live right now). When this defense gives way to
new adverse information, we go into an adjustment reaction–at first we overreact
a bit, then gradually settle down as our experience of the “new normal” includes
the facts of a pandemic. “It is important to scare people sufficiently (not
excessively, but sufficiently)–which is why strong messages are needed about the
probability and magnitude of the H5N1 risk.” We must let our patients know that
it is OK, even appropriate, to be scared.
8. Master the message and the communication. This is what we really have
to offer folks if this calamity strikes. This is not an obvious skill and thus
needs to be studied somewhat. There is an excellent online course (full set of
articles) on this very subject by Peter Sandman and Jody Lanard at
www.psandman.com/col/pandemic.htm). Here is what we as our community's medical
leaders need to say:
“1. Keep moving toward more and more emphatic messages about
the seriousness and likelihood of a pandemic. Apathy and lack of awareness are
still the big problems, not panic. Work to persuade journalists to use the
alarming parts of your quotes, not just the optimistic or low-end estimate they
are already using.
“2. Reduce the over-optimism in vaccine discussion. The next
flu pandemic will be the first flu pandemic for which it may be possible to
develop a vaccine in advance. We'd be fools not to try. But don't let the public
think that will 'prevent' the pandemic, or even keep it from causing worldwide
devastation.
“3. Broaden the focus beyond vaccine issues. Focus much, much
more on low-tech local problem-solving–on how individuals can (and will have to)
protect themselves, on how communities can (and will have to) get ready and cope
on their own, on how individuals and communities can help resolve tough national
and international dilemmas.
“And a fourth recommendation, to balance the other three:
Keep saying you might be wrong. Swine flu turned out to be a non-problem. SARS
receded, at least for now. H5N1 could do the same.
“But your gut and your expertise tell you that you're probably right. You need
to help us all get used to the idea of this new, huge threat. Then we need to
get busy together. And the best time to move forward is now, this winter, while
influenza is still on our minds and in the news.” [This was written in December
2004. If anything, the risk situation since then has become worse, not better.]
LATEST STATEMENT FROM THE SECRETARY OF HEALTH AND HUMAN SERVICES
[November 2006]
Dr. Mike Leavitt released this statement on
January 5th, 2006:“From the first appearance of H5N1 influenza in migrating
birds in Asia, we have recognized–and called attention to–the possibility that
they could carry the virus to other continents. While we are concerned about
today's report of human cases of H5N1 influenza in Eastern Turkey [and since
then in Africa], there is no evidence of sustained human-to-human
transmission–which is the hallmark of a potential pandemic. [Remember that by
time this happens, it is the pandemic; that is what a pandemic is–sustained
human-to-human transmission for which we have no treatment.] These cases
underscore the need for efforts undertaken by this Administration to improve our
pandemic influenza preparedness. We will continue our vigorous efforts in
concert with the WHO Secretariat, its regional offices and other international
partners to track the global spread of the H5N1 influenza virus and to detect
human cases as early as possible. We also will continue the aggressive work
within the United States to ensure early detection and reporting of
influenza-like illness, help municipalities prepare to counter an influenza
pandemic, increase stockpiles of antiviral drugs, develop vaccines against
potential pandemic virus strains, and enhance domestic vaccine products
capacity. [Here is where our political officials most seriously mislead us. As
the Chiron manufacturing failures showed us over a year ago, we have no adequate
in-country production even for ordinary flu. None of these hypothesized drugs or
vaccines will be on hand when the pandemic strikes. They should just say that.]
Neither the United States nor any other nation is as well prepared for an
influenza pandemic as it should be. But, through our ongoing efforts, we are
better prepared today than we were yesterday; and we will be better prepared
tomorrow than we are today.” COMMENT: It is time for physicians to start keeping
up with these stories. Www.pandemicflu.gov
is a good place to start. Bookmark it and check it regularly.
PANDEMIC FLU PLANNING CHECKLIST FOR INDIVIDUALS AND FAMILIES: Found on
the main website (www.pandemicflu.gov/planguide/checklist.html),
is the following advice:
1. To plan for a pandemic: Store a supply of water and
food. During a pandemic, if you cannot get to a store, or if stores are out of
supplies, it will be important for you to have extra supplies on hand. Ask you
doctor and insurance company if you can get an extra supply of your regular
prescriptions drugs. Have any nonprescription drugs and other health supplies on
hand, including pain relievers, stomach remedies, cough and cold medicines,
fluids with electrolytes, and vitamins. Talk with family members and loved ones
about how they would be cared for it they got sick, or what will be needed to
care for them in your home. Volunteer with local groups to prepare and assist
with emergency response. Get involved in your community as it works to prepare
for an influenza pandemic.
2. To limit the spread of germs and prevent infection: Teach your
children to wash hands frequently with soap and water, and model the correct
behavior. Teach your children to cover coughs and sneezes with tissues, and be
sure to model that behavior. Teach hour children to stay away from others as
much as possible if they are sick. Stay home from work and school if sick.
3. Items to have on hand for an extended stay at home: Examples of food
and non-perishables: ready-to-eat canned meats, fruits, vegetables, and soups;
protein or fruit bars; dry cereal or granola; peanut butter or nuts; dried
fruit; crackers; canned juices; bottle water; canned or jarred baby food and
formula; pet food.
Examples of medical, health, and emergency supplies: prescribed medical supplies
such as glucose and blood-pressure monitoring equipment; soap and water, or
alcohol-based hand wash; medicines for fever; thermometer; anti-diarrheal
medication; vitamins; fluids with electrolytes; cleansing agents/soap;
flashlight; batteries; portable radio; manual can opener; garbage bags; tissues,
toilet paper, disposable diapers. COMMENT: This is very serious stuff. Are you
prepared? I'm not either, but I am going to start. Visit the websites noted
above. They can help you get a serious introduction to this serious issue along
with numerous links relevant to both physicians and patients. Make it a habit to
check these sites at least once a month. You owe your community at least that.
AN UPDATE ON AVIAN FLU: Are we ready? Not by a long shot. This is an area
in which you should not wait for the experts. Consider what's known and decide
for yourself what it takes to be ready. Apply a filter of common sense to two
recent reports.
The first report is a statement on planning for avian
influenza in Ann Intern Med. Here are some excerpts: “Aside from agricultural
intervention to reduce the number of infected birds, the 3 major weapons for
controlling person-to-person spread are vaccine, antivirals, and social
distancing.” On vaccines, Dr. Barlett says, “The worldwide production capacity
for this vaccine would be enough to vaccinate a total of 75 million people,
which is about one fourth of the US population, or 1.25% of the world
population. Furthermore, using the current H5N1 vaccine as an example, only half
of vaccinated healthy persons might be protected against the target virus.
Finally, the target virus has already undergone antigenic change to a new clade.
The [American] College [of Medicine]'s recommendations for a vaccine supply
adequate for the entire US population are clearly not feasible now.” On
antiviral agents he adds, “Oseltamivir and zanamivir are about 60% effective in
preventing seasonal influenza, but their effectiveness for preventing pandemic
influenza is unknown. Oseltamivir had no clear effect on reported avian
influenza cases, but the evidence was not strong enough to draw any
conclusions.”
“Social distancing appears to be paramount but is not
completely understood. A recent model–based on analysis of the 1918-1919
influenza pandemic–estimates that in the United States, one third of
transmissions will occur in the household, one third in workplaces and schools,
and one third in the general community. The largest risk is having a household
member with influenza, and one of the most effective containment strategies is
early antiviral treatment of the index case and confinement to the home”
combined with prophylaxis of other household members. This obviously depends
both on the effectiveness of antivirals and on the availability, both of which
are unknown.
Dr. Bartlett asks the question, How can hospitals prepare?
“The U.S. health care system is fragmented, is financially distressed, operates
with 'just-in-time' supplies, and has minimal surge capacity. According to the
American Hospital Association, the average proportion of open beds is 4% to 6%
of total bed capacity, which means that a pandemic will quickly overwhelm
hospitals, intensive care units, and emergency departments...[A]n epidemic
comparable to that of 1918 would require 197% of hospital beds, 461% of
intensive care unit beds, and 198% of all available respirators. The gap between
our need for surge capacity in urban areas and our current resources is
staggering.” Federal funding to help is 'woefully inadequate' and that 'most
regions have no administrative structure to plan, to raise money, or require
hospitals to do their share of capacity building.'
He also criticizes the Federal planning for the pandemic:
“The part of this plan that appears most deficient is the last: regional
planning that includes local leadership, surveillance, effective communication
systems, methods to expand surge capacity, plans to maintain essential services,
identification of health care priorities, and guidelines for care. Most
communities haven't begun this work, at least not with an integrated regional
plan. For this there needs to be financial support, a timeline, and public
accountability for meeting deadlines. Pre-event planning is critical. Once
pandemic flu strikes a community, it is likely to be over in 3 to 4 months.”
Finally, he comments on the role of individual physicians and
health care workers. He concludes logically that they ought to be the highest
priority for vaccination, 'assuming a vaccine exists,' and for access to
antiviral agents. We need to resolve the controversy about the need for
negative-pressure rooms and N95 masks or powered air purifying respirators
versus surgical masks. He concludes with a discussion of the ethical obligations
of physicians in such a situation. “...AIDS, SARS, and smallpox have focused
attention on the duty to serve, and a consensus has emerged. The American
Medical Association Code of Medical Ethics states 'that a duty to serve
overrides autonomy rights in societal emergencies, even in cases that involve
personal risk to physicians.'” COMMENT: I don't think the AMA Code of Ethics is
going to hack it for most physicians. Deciding on the proper conduct when the
situation arrives is an individual matter. A reasonable and responsible decision
cannot be made without becoming informed. That's what we should be doing now. I
would suggest that there is no duty to take on high personal risk in carrying
out a task that is futile. You've got to know what is worth doing.
The Journal of Family Practice, a more practical, and
now evidence-based journal, offers its own take on a possible influenza
pandemic. It concedes that there will be a shortage of both vaccine and
antivirals. In an effort to be pragmatic, the authors offer “6 Steps to Proper
Management” in the “pandemic alert” phase of an epidemic, which I reproduce
along with my comments: [I expect the “pandemic alert phase,” once
human-to-human transmission is documented, to be so short in duration that it is
not of itself a significant event.]
1. Consider admitting the patient to a single-patient
hospital room. If this is not possible, take precautions to control infection in
the home. [As noted above, hospital resources are going to be exhausted
immediately. For practical planning expect to manage all patients at home.]
2. Notify local or state public health departments.
[Hopefully they will be all over this. If they're not, you're on your own. If
they don't know before you call, it's too late.]
3. Obtain clinical specimens requested by the public health
department. [In a pandemic, these specimens are not going to matter, and there
will be no resources available for either transporting them or processing them.]
4. Evaluate alternative diagnoses. [Generally, the only
meaningful alternative diagnosis is going to be bacterial pneumonia, which can
probably be either diagnosed by history or treated empirically after a telephone
consultation.]
5. Start antiviral treatment. [This is not likely to be
available after the first outbreak.]
6. Assist the public health department in locating potential
exposed contacts and provide prophylaxis. [Potential contacts will be
obvious–others in the home, classmates, and fellow workers.]
Their recommendations for home management are more practical:
a. Place the patient in a separate room or separate
physically for other household members as mush as possible. The patient should
remain isolated while most infectious (5 days after symptom onset). Consider
having the patient wear a surgical mask.
b. Do not allow non-household members to enter the home.
c. Limit the number of household members having contact with
the patient.
d. Follow hand hygiene after contact with the patient, the
patient environment, or waste products.
e. Consider having direct caregivers wear a surgical mask.
f. Wash dishes, utensils, and laundry in warm water and soap.
g. Consider antiviral prophylaxis for household members, if
it is available.
h. Have household members seek care as soon as they develop
symptoms of influenza. [ In general, they should just follow the protocol listed
above. There is nothing else to do.]
COMMENT: It's good to see that mainstream journals are starting to give this
issue the attention it deserves. While both reports acknowledge a general state
of unpreparedness, I don't believe either gets a handle on the practical
realities of this situation. Here are some of my thoughts:
1. You are a key player in your community. Talk about this and urge
preparedness and planning at every opportunity starting immediately. If a
pandemic strikes, all of the most valuable work will have been done beforehand.
2. As a key player, you have to protect your effective availability to
your community. During such a situation, your value is not likely to have much
to do with the traditional physician role of seeing patients in the office or
hospital, both of which are not likely to be functioning well, if at all. Since
the clinical steps of caring for persons with suspected/probable influenza are
straight forward, being available to counsel and guide remotely (i.e. by
telephone) is probably sufficient. It will not make sense to advise patients to
come to the office, nor the ED, nor the hospital. The home-based guidelines
above are probably adequate to save the majority of those who can be saved. For
the very sickest, history teaches us that not much can be done. There is little
point in attending directly on a patient unless you have something likely to
make a real difference. I personally don't believe that the role of assisting
compassionate resignation to one's fate by itself is worthy of taking on
additional risk. There will be plenty of risk to go around; use it wisely.
3. Key to survival for those who have survivable disease will be having
adequate nutritional and basic medical (first aid) necessities, and the
necessities of daily life. These will have to be procured in advance by
planning ahead. Once the pandemic arrives, stores will not be open.
4. While gloomy to anticipate, a key role for physicians will be to plan for the
handling of dead bodies, which we know will pile up rapidly in this situation,
as morgues and funeral homes are overrun.
5. In a pandemic situation only two groups of citizens will survive–-those
who are just plain lucky and those who planned and executed their
plans. Your job is to assist the latter group, in advance, as much as
possible.