H1N1 flu is slowing down, gives room to front-line
H1N1 flu is slowing down, gives room to front-line
So far, so good — but what's next?
[Editor's note: Drug Formulary Review presents a look at how pharmacy disaster planning experts have handled the recent novel H1N1 influenza A crisis in a two-part series. In this issue, hospital pharmacy experts discuss ways to educate and prepare the public during a pandemic. Also, there's a sample H1N1 public health report and guidelines from the federal government on providing prophylaxis antiviral treatment. In the June 2009 issue, there are articles about the importance of communication during disaster preparation, and one hospital pharmacist outlines what she and her staff learned from an infectious disease disaster drill early in 2009.]
Just as quickly as the world media touted the novel H1N1 Influenza A as the next 1918 pandemic, the media turned on itself to say it was all much ado about nothing.
But hospital pharmacists and emergency planners know better: What the first run of this novel flu outbreak has shown is that Mexico's health care system and governmental crackdown on stopping the flu's spread was successful. And it has demonstrated that U.S. hospitals are well-prepared to handle both seasonal flu epidemics, as well as outbreaks of novel influenza virus.
The Mexican government's response was swift and sacrificed its own economy as restaurants, schools, and other non-essential businesses and events were shut down to prevent the flu's spread. Travel to Mexico also plummeted. The Drug Information Association (DIA), for example, postponed its 2nd Latin American Regulatory Conference, which was scheduled for May 13-15, 2009, in Mexico City, Mexico.
True, no single U.S. hospital's infrastructure was taxed by an influx of flu cases, but most appeared to be ready. Also, pharmacist emergency planners say this dry run will make it even more likely that hospitals will be ready for the fall and winter flu season, even if H1N1 makes a more deadly and virulent comeback.
"My suspicion is there will be a second wave of this flu variant," says Deborah J. Larison, PharmD, BCPS, clinical pharmacy specialist in emergency medicine at Sarasota Memorial Hospital in Sarasota, FL.
"With the 1918 influenza outbreak, the first wave was slightly less serious and was easily transmissible, but the second wave of that pandemic had more severe consequences than the first wave," Larison explains. "So there's always the possibility that a second wave could be worse."
During the first wave of the H1N1 outbreak, Sarasota County and the Florida Department of Health produced H1N1 flu situation reports with status information and guidelines for health care providers and the public.
In many ways, the way hospitals typically prepare for seasonal flu is how they should prepare for the H1N1 flu, says Carsten Evans, PhD, FASHP, assistant dean in continuing professional education in the College of Pharmacy at Nova Southeastern University in Fort Lauderdale, FL.
"In a normal flu season we lose 32,000 people," Evans says. "I think the same things we normally do we should be doing all along."
What made H1N1 different is the public attention and potential for panic surrounding the outbreak.
Although the novel influenza virus proved no more deadly than the typical seasonal flu, there was a great deal more attention paid to each death and hospitalization associated with it.
And if it resurges this fall in a more virulent form, then there's reason to suspect the public will be both alarmed and attentive.
So in some ways what hospital pharmacists need to do is educate and prepare in the event of public panic. Here are some suggestions:
• Educate about infectious disease safety measures: For instance, hospital pharmacists can emphasize social distancing among staff and patients, encouraging people to give a little extra space between themselves and others during flu season, Evans suggests.
They can provide information about the proper use of personal protective equipment, including painter's masks or surgical masks, he notes.
"There are certain things we want pharmacists to preach about," Evans adds. "And when panic strikes they can do this."
Hospitals could put up signs about good hand hygiene and how to wear masks safely, says Sharon S. Cohen, RN, MSN, CEN, CCRN, an emergency preparedness clinical nurse specialist/instructor trainer with the department of emergency preparedness at Broward Health in Fort Lauderdale, FL. (See Broward County's tips.)
"If people are very sick with respiratory illness, we try to create a respiratory section that's away from the emergency department population that doesn't have influenza," Cohen adds. "We teach mask, hand-washing, and cough etiquette, and we have masks that nurses can give to patients."
"If someone presents with a fever and other signs and symptoms characteristic of the flu, we offer them a mask," says Richard G. Thomas, PharmD, DABAT, emergency management coordinator in the emergency department and rapid treatment unit pharmacist at Primary Children's Medical Center in Salt Lake City, UT.
"We'll isolate them only if we have cause to do so, and then we'll take appropriate respiratory protection," Thomas says.
• Assist with comorbidities: Pharmacists assist with preventing drug-drug interactions in cases of patients who have a chronic disease and present with influenza symptoms, Cohen says.
"We have a large HIV population, and we look at the whole pharmaceutical perspective of the patient," she explains. "They're on such complicated protease inhibitor-type of regimens that we want to make sure we're managing their HIV and treating whatever illness it is they present with."
• Screen for prophylaxis treatment: The U. S. Department of Health and Human Services has extensive guidelines on antiviral drug use during an influenza pandemic, and these include details about providing both pre- and post-exposure prophylaxis.
"The guidelines are relatively broad both for prophylaxis and treating patients who are hospitalized," Thomas says.
"So if you have a child who presented in the emergency department, treat that child with a full-course antiviral," Thomas suggests. "Treat family contacts with prophylaxis, as well."
With an adult who has the same symptoms in the emergency department, anti-flu prophylaxis is not necessarily recommended, he adds.
• Maintain adequate supply of drugs necessary during pandemic: "Look at your hospital's drug supply and try to forecast what you'll need," suggests Erin Mullen, RPh, PhD, assistant vice president for Rx Response, a Washington, DC-based coalition that includes PhRMA.
Since the H1N1 novel influenza outbreak occurred at the end of the normal flu season, hospitals typically would have a decreased amount of antivirals on hand, Mullen notes.
"There were some limited shortages, but not because the product is not available, but because it takes a couple of days for the supply system to fill itself up when there's increased demand," Mullen explains. "So when you're looking ahead to what's going on, you should make sure there's additional stock on hand for what you'll need to respond."
For instance, hospital pharmacists should look at both what they need for handling an influenza pandemic, including antivirals like oseltamivir (Tamiflu®), as well as treatments needed for secondary infections, such as antibiotics needed for treating pneumonia, Mullen says.
"Also, hospitals will need other respiratory support medicines, IV fluid, etc., and they should make sure those stocks are adequate," she adds.
The Joint Commission on Accreditation of Healthcare Organizations recommends a 96-hour supply in stock, Mullen notes.
• Lead efforts to extend reach of available flu drug supply: If there proves to be a true pandemic with more people heading to the emergency room and hospital than usual and more people requesting oseltamivir and other antivirals, exhausting available supplies, then there are additional ways hospital pharmacists can help, Evans says.
For example, hospital pharmacists can come up with strategies for extending oseltamivir doses.
"If you have symptoms of flu you are supposed to take one Tamiflu tablet twice a day," Evans says. "That should help you get through the symptoms."
People who want to take the drug as a prophylaxis should take it once a day for 10 days, he adds.
But in a pandemic situation it might be necessary to cut down on these doses so more people can be protected and helped.
"So you can take certain drugs and extend the life of these products," Evans says.
For instance, the drug probiticide can help slow down the metabolism of oseltamivir, meaning that taking the flu drug with probiticide every third day could mean that fewer doses of oseltamivir would still have a desirable prophylactic impact, Evans explains.
This is an emergency situation possibility, however.
"Pharmacists would have to figure this out based on four research papers," he adds. "Pharmacists understand what probiticide's capabilities are, but they haven't been taught about using it with Tamiflu."
[Editor's note: Drug Formulary Review presents a look at how pharmacy disaster planning experts have handled the recent novel H1N1 influenza A crisis in a two-part series. In this issue, hospital pharmacy experts discuss ways to educate and prepare the public during a pandemic. Also, there's a sample H1N1 public health report and guidelines from the federal government on providing prophylaxis antiviral treatment. In the June 2009 issue, there are articles about the importance of communication during disaster preparation, and one hospital pharmacist outlines what she and her staff learned from an infectious disease disaster drill early in 2009.]Subscribe Now for Access
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