Pandemic survival guide: Be prepared and don't wait for the feds

Hospitals must stockpile, prepare for the worst, plan says

Neighborhoods are sealed off with barbed wire fences. The trucking industry has collapsed, and basics such as food and medicine are in short supply. Businesses and schools are closed, hospitals are overflowing, and nurses are walking off the job. This is like Hurricane Katrina hitting in every state at the same time, a government leader says.

Is this a made-for-TV movie or a scenario in the federal plan?

That dire scene was portrayed in the ABC movie on bird flu; it reflected some of the worst-case predictions contained in federal plans. The implementation plan of the National Strategy for Pandemic Influenza, released in May, cautions that as much as 40% of the work force could be out sick during a pandemic peak. (The report is available at www.npr.org/documents/2006/may/birdfluplan.pdf.)

Hospitals should consider these possibilities as they draft pandemic influenza plans, experts say. They should already be working with their state and local health departments and hospital associations to coordinate planning, says Deborah Levy, PhD, MPH, senior adviser for health care preparedness at the division of health care promotion at the Centers for Disease Control and Prevention in Atlanta.

One fact portrayed vividly in the movie, underpinning even the federal plan: The federal government will have a stockpile and multi-agency tasks, but the ultimate response will be local. That is a message Health and Human Services Secretary Michael Leavitt brought across the country as he traveled state-to-state this past year.

"You can't wait for the feds to be the cavalry to come over the hill to rescue you," echoes William Schaffner, MD, chair of the department of preventive medicine at Vanderbilt University in Nashville. "This is not like a hurricane where the impact is delineated in impact and time, and once it's over, it's over. Pandemic flu is going to hit many sites in the U.S. in a scattered fashion over time. There will be second waves."

Hospitals vary greatly in the extent of their pandemic preparedness. But in most communities, their efforts far exceed those of other businesses and community organizations. Hospitals, along with public health departments, need to be a leader in the coordination efforts, says Schaffner. "The issue is who's got the resources, who has the clout, who has the determination to be the local community coordinator," he says.

We don't need to think back to severe acute respiratory syndrome to find a parallel for the potential spread of pandemic influenza, he says. This year, mumps outbreaks have occurred throughout the Midwest. The strain matches one that caused widespread outbreaks in the United Kingdom and apparently was spread by international air travel.

"Mumps is a bit of a fire drill," Schaffner says. "Despite the fact that we had a well-immunized population, this disease spread and continues to spread and amazes me with how tenacious it is. You can imagine how an infectious disease that's more transmissible and less distinctive can rapidly spread."

In fact, influenza is transmissible before symptoms appear, and its incubation period is only two days.

Planning efforts seek to answer some basic questions:

• Will you have enough supplies?

Transportation will be curtailed if a pandemic occurs, and some countries may completely shut their borders, severing trade, according to the federal implementation plan. It recommends "developing contingency plans to address lack of essential services, including delivery of essential commodities such as chlorine for water purification, gasoline, food, fuel, and medical supplies."

The federal implementation plan also advises hospitals to stockpile food, fuel, personal protective equipment, and other essential items that could last two or three weeks and to identify emergency sources. (See box below.)

What hospitals should do

Here are some general directives for hospitals and health care facilities contained in the federal implementation plan:
  • All health care facilities should develop, test, and be prepared to implement infection control campaigns for pandemic influenza within six months.
  • All hospitals should be prepared to treat patients with pandemic influenza (i.e., equipped and ready to care for: 1) a limited number of patients infected with a pandemic influenza virus, or other novel strain of influenza, as part of normal operations; and 2) a large number of patients in the event of escalating transmission of pandemic influenza).
  • All hospitals and health care systems should develop, test, and be ready to employ business continuity plans and identify the critical links in their supply chains as well as sources of emergency.
  • All health care systems, individually or collaborating with other facilities to develop local or regional stockpiles maintained under vendor-managed inventory systems, should consider stockpiling consumable critical medical materiel (including but not limited to food, fuel, water, N95 respirators, surgical and/or procedural masks, gowns, and ethyl alcohol-based gels) sufficient for the peak period of a pandemic wave (two to three weeks).

That means a fundamental shift in the just-in-time policy that predominates in most hospitals.

For example, Sharp Memorial Hospital in San Diego is purchasing a stockpile of masks and N95-filtering facepiece respirators, but asking the distributor to hold the products in the warehouse, says Shannon Oriola, RN, CIC, COHN, lead infection control practitioner at Sharp Metropolitan Medical Campus. The hospital doesn't have enough storage space to keep the items — a problem shared by many hospitals, she says.

• Will there be available vaccine and antivirals?

Vaccination and antiviral medications are a critical part of the federal response to pandemic influenza. The plan assumes that if a pandemic occurs, the United States will not be able to obtain any vaccine manufactured in other countries.

States have been asked to create antiviral stockpiles that total 31 million treatment courses, while the national stockpile will have about 50 million treatment courses. The national stockpile also will include about 20 million courses of pre-pandemic vaccine.

The ultimate goal: Within five years, the federal government wants the domestic vaccine capability to manufacture 300 million courses of vaccine within six months of development of a reference strain — or enough to vaccinate every American.

That will require an advance in technology, and the federal government has provided grants to pharmaceutical companies to develop a new cell-based method of making flu vaccine.

Meanwhile, the first doses of available vaccine would go to critical health care workers and first responders. But creating a huge vaccine stockpile doesn't make sense in the absence of human-to-human transmission of H5N1, says influenza vaccine expert John Treanor, MD, professor of medicine at the University of Rochester (NY) Medical Center.

Likewise, there isn't enough evidence to support pre-pandemic vaccination of health care workers or other critical workers. "Right now, I think the likelihood of a pandemic is still not high enough that it makes sense to go forward and do that," he says.

• If vaccine is limited, who will be the first to receive it?

You can expect some further guidance from the Department of Health and Human Services (HHS) on the highest priority workers who will be the first to receive available vaccine or antivirals. But hospitals also should look closely at their critical personnel needs, says Levy.

"On the federal level, we are looking at that issue and providing some guidance, but it will only be guidance," she says. "Implementation rests on the shoulder of facilities."

For example, the emergency department and intensive care unit may be obvious priorities, but how many employees does it take to run those units? Who are they? "If they had to decide who was critical to the function of the hospital and taking care of patients, who would that be?" Levy says.

Keep in mind that you'll need more than clinical employees, she notes. Dietary workers, housekeepers, maintenance staff, and security also will be critical.

• Will you have enough staff?

In the ABC movie on the bird flu, one nurse grabs an armful of masks and begins to leave. When another nurse tells her how badly she's needed to treat the overwhelming number of patients, she says, "My mama and my little boy are sick at home, and it was probably me that got them that way. I'm not doing this anymore and you're not making me feel guilty about it."

That is a fictional, dramatized moment. But hospitals also need to consider how they would cope with massive absenteeism as employees become sick and others are fearful to report to work.

According to the federal implementation plan, HHS is working with state and local governments to expand the Medical Reserve Corps by 20%. Volunteer health care workers, such as retired nurses and physicians, will be recruited to help treat patients during a pandemic.

Employee health professionals will need a speedy way to provide orientation on the hospital's safety devices and procedures, says Oriola. Mean-while, your current employees need education on avian influenza and pandemic planning, she says.

At Sharp Memorial, health care workers with direct patient care responsibilities are required to participate in the on-line educational module. Other workers also will receive targeted education. The hospital will emphasize their importance to the organization, she says.

"If you work in a hospital, you're essential, whether you're a janitor or a nurse," she says. "Everyone is needed to make it run."