| Contents | Previous | Next |
In planning for a pandemic, five areas need to be covered. These include:
Surveillance and laboratory issues include establishing global and local data collection systems in order to know expected disease rates in humans and animals so that an increase is recognized as quickly as possible. It also includes developing laboratory infrastructure and expertise to handle specimens accurately in a timely manner.
The Federal Emergency Management Agency (FEMA) requires that all planning for various hazards/disasters/terrorist acts follow the Incident Command System (ICS). This system provides a structure for the flow of information to the participants responding to the emergency and reciprocal response back to those in authority.
The second planning area is communication among all those who will be involved in a response on local, state, and federal levels. Influenza pandemic would require multiple agencies, organizations, and community groups to effectively respond and therefore, in many areas, they would be under the local ICS (Incident Command System).
In addition, communication includes accurate, frequent, concise, and timely information for the public by a primary spokesperson. Health experts should use interactions with media personnel to provide educational points about the transmission, prevention, and symptoms of influenza. Such points, referred to as “sound bites,” are brief, accurate, in common language, and important.
Create plans to educate the public with accurate information and means of correcting false or misleading information.
Create patient education materials before the flu season to assist patients in remembering what they have been told and increase their participation in preventing the flu, as well as caring for themselves (or someone else) with the flu.
A depleted workforce could be a byproduct of a pandemic, therefore the third area in a preparedness plan is the maintenance of community services from healthcare providers. This may involve providing vaccine first to healthcare professionals and those responsible for essential services in the community. Some services may need to be done via telecommuting so that more people can stay at home and lessen their exposure to the influenza virus.
Medical care is another area that will be heavily impacted in a pandemic. Quarantine may be imposed to those who have been exposed, as needed, to slow the spread of disease. Equipment and care may have to be prioritized and possibly rationed.
Some hospitals, health departments and other medical facilities are developing lists of nurses who are no longer practicing or are retired and might be available to assist during a crisis if needed. (Gensheimer K, Meltzer MI, Postema A, and Strikas RA.)
Local health departments have plans and agreements with the American Red Cross and other organizations to establish shelters. Normally, these shelters are for people who have been displaced/evacuated because of a natural event (fire, flood, earthquake).
It may be necessary to set up shelters for medically fragile people. A shelter for medically fragile people has additional equipment and staffing needs. Such a shelter would be for people who require help with medical treatment, such as wound care, medications, and IVs. People who are too sick to care for themselves and have no one to care for them would be appropriate referrals for a medically fragile shelter.
The supply and delivery of vaccines and drugs needs examination. Currently, those with high risk of complications from the flu are the first to receive the vaccine if a shortage is anticipated or production is slow.
In a pandemic, the decision may be made that healthcare professionals and others providing essential services would be the first recipients of vaccine. Because the vaccine would be completely new to a person’s immune system, it may be that two doses 30 days apart will be needed to produce immunity, as is the current practice for children younger than 9 years of age receiving influenza vaccine for the first time.
During a normal flu outbreak emergency rooms are often overbooked today. Imagine what a pandemic would look like. Therefore, during a pandemic, things would have to change. Would someone have to make the decision to ration ‘care’ such as a respirator? In other words, who would have to decide if the 25-year old should get treatment versus a 55-year old?
It was suggested as a result of the recent SARS outbreak to evaluate the following model in case of pandemic illness: (Leighty J. Code Zebra: On the Frontlines, California Eds Brace for Action Against Infectious Disease and Bioterrorism. Nurse Week. 31 May 2004; 13-15.):
At first glance, the subject of bird farm containment may not appear to be related to the focus of this text. However, it is important for the nurse to at least be aware of the small “backyard” chicken farmer. For example, in more rural areas, there are people who have chickens as pets. Thus, in our collective efforts to help contain the spread of infected birds, a mention here seems appropriate.
Live bird markets have been an important source of avian influenza, especially on the East coast of the U.S. It is important to avoid live markets, educate employees about the dangers posed by these markets, and prevent the spread of disease from these markets by preventing any contact. Wild birds and their excreta should be considered a major source of avian influenza. Preventing direct contact with free-flying birds and protecting domestic poultry from contact with the feces of wild birds is an important way to prevent avian influenza.
Signs of avian influenza are extremely variable. In some flocks the only evidence of the infection is seroconversion i.e., the birds develop a detectable antibody titer that can manifest as respiratory, enteric, reproductive or nervous system disease. Decreased food consumption and drops in egg production are among some of the earliest and most predictable signs of disease. Coughing, sneezing, ruffled feathers, swollen heads, nervous signs like depression, and diarrhea may occur together or singly. In some cases, birds die rapidly without clinical signs of disease.
Infected birds shed virus in saliva, nasal secretions and feces in the first two weeks of infection. Four weeks after infection, virus can no longer be detected. Hence, prevention is best accomplished by preventing contact between newly infected and susceptible birds.
Some backyard chicken farmers use double fencing or fences within fences. Roofing is important to prevent contamination from wild bird droppings. The main gate also serves to prevent access by unauthorized persons including curious children.
Although it is not highlighted in the media, swine could become the intermediate carrier of H5N1 prior to pandemic. It is essential to prevent the viral spread now among other animals and people. Here are some suggestions:
Some communities are developing plans, others are in the “uh, the bird flu is just a way to scare us” stage. As evidenced by the lack of planning by city and county fire departments and hospitals, and as other first respondents demonstrated in New Orleans, there is definitely room for improvement in terms of communication and coordination between agencies during emergencies.
It is critical to identify your hospital’s current strengths and gaps in recognizing and responding to suspected infectious cases, with specific attention paid to policies, resources, communication, and coordination issues:
Below are some basic suggestions for individuals/families or communities to consider:
The following supplies should be kept in a convenient place for use if the power goes out.
In the event of interruption of water service, it will be necessary to treat water before using it. There are four acceptable methods:
Boiling is the safest method of treating water. Boiling water kills bacteria and parasites. Bringing water to a rolling boil for 1 minute will kill most organisms.
Chlorination uses liquid chlorine bleach to kill microorganisms such as bacteria. Use regular household liquid bleach that contains no soap or scents and has sodium hypochlorite as the only active ingredient.
Add six drops (1/8 teaspoon) of unscented bleach per gallon of water, stir and let stand for 30 minutes. If the water does not taste and smell of chlorine at that point, add another dose and let stand another 15 minutes. This treatment will not kill parasitic organisms.
Water treatment purification tablets release chlorine or iodine. They are inexpensive and available at most sporting goods stores.
NOTE: People with hidden or chronic liver or kidney disease may be adversely affected by iodized tablets and may experience worsened health problems as a result of ingestion. Iodized tablets are safe for healthy, physically fit adults and should be used only if supplies for boiling, chlorination and distillation are not available.
Distillation involves boiling water and collecting the vapor that condenses back to water. The condensed vapor may include salt or other impurities.
Food items that you might consider including in your disaster supply kit include: ready-to-eat meats, fruits, and vegetables, canned or boxed juices, milk, and soup; high-energy foods like peanut butter, jelly, low-sodium crackers, granola bars, trail mix; vitamins; instant coffee, cereals, and powdered milk.
FEMS suggests that the following items be stocked:
Items should be rotated every two years. Bulk quantities of wheat, corn, beans and salt have nearly unlimited shelf life.
Fear is spreading globally regarding the popularized avian flu and we can see by the daily numerical increases and geographic spread that it is a justified alarm. Although it may, or may not, morph into a major pandemic, the probability is that a pandemic will occur. Perhaps the next pandemic or contagious disease will be from a yet unknown vector. However, as a global entity we collectively have a responsibility to prepare for the unseen but potentially lethal microbial attack. It is like waiting for a storm with threatening clouds on the horizon.
Preparing for a pandemic requires the leveraging of all instruments of national power, and coordinated action by all segments of government and society. The next pandemic is likely to come in waves, each lasting months, and will ultimately threaten critical infrastructure by removing essential personnel from the workplace for weeks or months.
This makes a pandemic a unique circumstance necessitating a global strategy that extends well beyond health and medical boundaries, to include the infrastructure, private-sector activities, the movement of goods and services across the nation and the globe, and economic and security considerations.
While no one can predict the timing or severity of the next influenza pandemic, (or any other pandemic) governments around the world are taking the threat seriously. A series of international meetings have been held worldwide to work towards a global consensus for controlling the disease in animals while simultaneously preparing for a potential human pandemic.
The first meeting of the Partnership took place on October 6-7, 2005 in Washington, DC, hosted by the U.S. Department of State. The meeting involved top foreign affairs, health and agriculture officials from 88 countries, as well as representatives from eight international organizations, including the World Health Organization, the Food and Agricultural Organization and the World Organization for Animal Health.
“It’s impossible to exaggerate how important pandemic preparedness is, and how dire the consequences would be for the entire world if some of the worst-case scenarios for a human influenza pandemic were to unfold,” says James Adams, the World Bank’s Vice-President for Operations Policy and Country Services, and head of the Bank’s avian flu taskforce. The meetings provide an opportunity for international partners to mobilize the country commitment and financial resources needed to manage this global threat.
Five primary goals of the International Partnership are:
The WHO is advising its member states to develop national strategies to cope with such a public health emergency, as well as coordinating with international partners to develop a comprehensive response. “Influenza and pneumonia will continue to be our leading infectious disease killers even after the full arrival of West Nile Virus or SARS.” (Deckert, AW. Unpublished Health Officer’s Report. Communicable Disease: Influenza Prevention. September, 2003).
When the next pandemic occurs, the combined advances of improved medical care, modern pharmaceuticals, and intensive care medicines, might avoid some of the carnage. In the event of a pandemic, emergency departments will be flooded with hoards of people screaming for antivirals, antibiotics and climbing over one another to get their loved ones into the few intensive care beds that exist. It is easy to imagine this panic as we have already had a glimpse with recent world events (tsunamis and hurricanes).
According to the U.S. government information on pandemic flu and avian influenza the message is clear: “Get informed, be prepared”. We know that there is an increasing threat that chemical and biological weapons will be used on a civilian population in an act of domestic terrorism. We are seeing the microbial evolution of new lethal influenzas as the H5N1 spreads and are reported in daily news. The new reality of more research laboratories working with more exotic microbial material increases the chance of genetic accidents. The mathematical evidence indicating disruption seems logical.
Pandemic influenza can create a financial burden on the community and health care system. Business conditions will deteriorate as the health care system endures higher costs and reduced revenues.
Public health is on the front lines. Crisis management as has been historically demonstrated will most likely be ineffective. Surveillance for early recognition of disease problems, effective response to prevent the spread of disease, and better predictive capabilities are essential, which have traditionally been under-resourced. It is necessary to sustain public health capabilities by creating better systems domestically and internationally.
Political will is essential. Although there is a trickle of additional financial resources to focus attention towards problems that may emerge or are here now, much more needs to happen quickly. Perhaps it took the September 11th tragedy to raise awareness, or the terrible disruptions created by Katrina, the New Orleans 2005 hurricane. Maybe it will take frightening deaths from a new influenza, a new pandemic or, perhaps, some other form of catastrophic event to realize that we are in this together. Political incentive is usually financial. With sick and dying the financial costs will soar beyond the imaginable and could create economic disasters world over.
In 2003 influenza and pneumonia hospitalized more than 114,000 people, killed approximately 36,000, and cost more than $12 billion dollars in the USA. In 2005, President Bush allocated 7 billion dollars to prevent a global fiscal disaster, (i.e., the avian flu pandemic) as outlined in a recent Bush presentation. To be put into perspective, consider this: Star Wars, a popular movie, grossed 3 billion in sales revenues. Today it is costing U.S. taxpayers about 1 billion per day to be fighting in Iraq. You do the math.
The Bush Administration in 2005 launched the National Bio-surveillance Initiative to rapidly detect, quantify and respond to outbreaks of disease in humans and animals and, furthermore, to deliver information to state, local, national and international public health officials.
Protecting the American people by stockpiling vaccines and antiviral drugs, and accelerating the development of new vaccine is another strategy undertaken by the Bush Administration. However, one of the challenges presented by a pandemic is that scientists need a sample of the new strain before they can produce a vaccine against it.
Researchers at the NIH have developed a vaccine based on the current strain of the avian flu virus; the vaccine is already in clinical trials; however, as mentioned, this disease has not yet morphed into the feared pandemic. Because it is difficult to produce a pandemic vaccine before the pandemic actually appears, there may not be a vaccine capable of fully immunizing people. President Bush signed into law Project BioShield, an unprecedented, $5.6 billion effort to develop vaccines and other medical responses to biological, chemical, nuclear, and radiological weapons. In the past three years, the Administration has created the BioWatch program to monitor major cities for a biological release significantly increased stocks of antibiotics against anthrax.
In May 2005, the U.S. Secretary of HHS created a multi-agency National Influenza Pandemic Preparedness and Response Task Group. This unified initiative involves CDC and many other agencies (international, national, state, local and private) in planning for a potential pandemic. Its responsibility includes revision of a U.S. National Pandemic Influenza Response and Preparedness Plan.
Because of these differences and the expected size of influenza pandemic, it is important to plan preparedness activities that will permit a prompt and effective public health response. The U.S. Department of Health and Human Services (HHS) supports pandemic influenza activities in the areas of surveillance (detection), vaccine development/production, strategic stockpiling of antiviral medications, research, and risk communications.
Communities are on the front lines of a pandemic and will face many challenges in maintaining continuity of society in the face of widespread illness and increased demand on most essential government services.
The disaster plan is considered to be the most important preparedness tool. While associated with hospitals and large institutions, office based practices also need a plan. Communities, neighborhoods, and families need to also have one in place as well.
Among the most essential competencies are the ability to locate your institutional or office disaster plan, to understand your role in an emergency; and to know how to communicate with patients, ancillary staff and governmental agencies during an emergency.
As clinicians, we have the added responsibility of becoming familiar with the chemical, biological, radiological, nuclear, and explosive agents of concern. Now is the time to study the ‘what if’s,’ not when the ambulances are rushing by.
In conclusion, there are infectious diseases heading our way, which many believe are inevitable, and, deadly, causing massive global casualties. We’re living through a health crisis of mind-boggling proportions: with infectious disease on the move.
If the problem were isolated to one virus, one bacterium, we’d be fortunate. Unfortunately, several infectious disease scenarios are unfolding simultaneously as we’ve seen in this text. Infectious diseases, once thought of as being conquered, are coming back with an unstoppable vengeance. Antibiotics have lost their punch. We stand poised to witness one of history’s largest population calamities ever recorded.
The daily warnings from the media of plagues, pandemics, bird flu’s, and bioterror serve as reminders that although things appear normal, they may not stay that way. As a society, we live pampered lives, watching daily television and expecting problems to be fixed instantly. It’s as though the public has filters that screening out what it doesn’t want to hear.
Viruses and bacteria travel faster than television news. By the time we hear the “pandemic” is in your town, it will be a bit late to plan. History has shown throughout the ages cruelties bestowed upon man. The facts indicate it is not a matter of if, but when.
Nurses will be among the “first” responders. Staying healthy and understanding ways to create strong immunity are essential. The nurse who understands epidemiology, the psychological responses to fear, and what can happen, will remain calmer should the worst scenario materialize in reality.
The nurse, aware of clinical signs regarding some of the more exotic potential illnesses and odd clustering, will be in a better position than the nurse who is surprised at the possibility. The nurse can become instrumental in the preparation work that is being conceived today, as well as possibly lobbying political representatives for additional money for hospitals or public health.
As surveillance systems get into place as a result of the increased financial allocations, we will collectively be able to avoid widespread chaos. Biosense is a state of the art, multi-jurisdictional, data-sharing program to facilitate surveillance of unusual patterns or clusters around the country. The hope is that this will help to rapidly detect and quantify public health emergencies by enabling rapid access and analysis of diagnostic health data. Public Health emergency programs such as the CDC Public are providing states with resources to strengthen abilities to respond to natural disaster, infectious diseases, or inflicted bioterror.
Improved surveillance and well-orchestrated communication is needed. More research needs to be done to help understand the factors that foster emergence of infectious diseases, and to develop diagnosis, treatment, and prevention tactics.
Coordination in planning and consistency in implementation with other emergency response plans are essential. The production and ability to administer vaccine to large numbers of people in a short amount of time needs focus. Systems in the infrastructure, hospital crisis plans need to be recognized. New frameworks for nurses need added definition.
Individuals, communities, and families need to prepare as much as possible while the opportunity is available. Public education and behavioral change is needed to prevent continued spread of diseases through travel, poor personal hygiene, improper food handling, drug abuse, and high-risk sexual behavior. Nurses have a great opportunity now to produce and disseminate educational information to people in an effort to quell mounting fear.
Vector control must be examined to limit the spread of diseases transmitted by such vectors as insects and rodents. The bedbug epidemic as shown on Prime Time (television program) in 2006 is an example of the need for ‘vector control.’
We will need to reassess when going to work is appropriate and when it is not. Employers may want to create a better ‘sick’ program so that workers can stay home if infected with contagious illness. Perhaps telecommuting programs can begin to be established.
Get involved with your hospital’s preparation plan, check your neighborhood, prepare yourself, and your home. Some people worry, while others prepare as best they can. No one can predict the future, as there are too many unknowns. Being prepared for what many believe is the inevitable cannot be done overnight. It cannot be created in a vacuum, nor can nurses make it happen alone. A deeper consciousness and a willingness to take a good look, and develop a plan will be helpful in the future.
Remember, as seen within this text, there are trends and facts that could add up to potential problems in the near future. It is in that context, that I hope this course will inspire you to become proactive in your hospital, community, or family, one step at a time.