Expert says pandemic flu would be much worse than SARS outbreak

CDC guidance document urges preparedness

Hospitals need to ramp up their preparedness for pandemic influenza, a threat that is heightened by the continuing spread of avian influenza among birds and mammals in Asia, cautions the Centers for Disease Control and Prevention (CDC).

The U.S. Department of Health and Human Services issued a draft guidance document on pandemic influenza preparedness, with a section focused on hospitals (www.hhs.gov/nvpo/pandemicplan/annex2.pdf). Meanwhile, some hospitals are altering their fall influenza campaigns because of a delay in the distribution of about half the nation’s flu vaccine.

"It’s worth remembering that there’s been no other event in U.S. history that has killed as many people as the 1918 influenza pandemic," says Ben Schwartz, MD, senior science adviser in the National Vaccine Program Office, noting that 675,000 Americans died from the 1918 Spanish flu.

Better health care and antiviral medications could prevent many deaths, but the impact on the health care system from pandemic influenza would be severe, he notes. In fact, pandemic flu would make severe acute respiratory syndrome (SARS) look like a minor outbreak.

"An outbreak of influenza in a community may result in about one-third of the entire community becoming ill, whereas SARS caused fewer than 1,000 cases locally," he says. "There would, obviously, be a big difference in the impact of the two on the health care community."

Yet many hospitals have not focused their preparedness on pandemic influenza, Schwartz says. "When I talked with [hospital infection control practitioners] about pandemic flu, the response I got was that they had preparedness burnout. They were busy working on bioterrorism; they were busy working on SARS," he adds.

The draft guidance document outlines the similarities and differences between SARS and pandemic influenza. It recommends creating an all-hazards plan but maintaining distinct portions of the plan to address specific hazards such as pandemic flu and SARS.

"One of the reasons for having a separate pandemic flu preparedness plan is to highlight what is important and what is unique about influenza," Schwartz explains.

How would you use limited resources during a pandemic influenza outbreak? That is a key question addressed in the preparedness document.

Your staff would be among your most critical resources. The CDC recommends hospitals coordinate their preparedness with state and local health departments and other health care facilities in the community. But you won’t be able to count on help from other hospitals in your area or even around the country, Schwartz cautions. They all will be facing a similar crisis.

"Early in the pandemic before a vaccine is widely available, good health care is going to be the intervention that prevents people from dying," he says. "The question becomes, how do we maintain the capacity of the system?"

Hospitals may need to move health care workers from nonclinical to patient care areas. They may need to tap into student nurses, volunteers, and retirees, Schwartz adds. FluSurge software, a planning tool available from the National Vaccine Program Office web site (www.cdc.gov/flu/flusurge.htm), enables hospitals to estimate how many patients would be hospitalized and how many would need intensive care with pandemics of varying severity.

Meanwhile, hospitals need to consider how they would allocate scarce supplies of vaccines and antiviral medications.

"It will take months for those first supplies of vaccine to come off the line," says William Schaffner, MD, chair of the department of preventive medicine at Vanderbilt University School of Medicine in Nashville, TN, and a board member of the National Foundation for Infectious Diseases.

"Public health will be tracking exactly where influenza is going. It won’t strike all parts of the world simultaneously," he says. "We’ll have even more time to develop drugs and even vaccines. But there will be a time when there won’t be enough vaccine, and there won’t be enough drug to give everyone. We’ll have to prioritize."

Antivirals may be effective as a prophylactic agent, but that isn’t an efficient use, Schwartz explains. Health care workers would need to take it continuously to prevent infection, but could take it as soon as early symptoms appear to reduce the severity and duration of the disease.

Health care workers with more mild symptoms might work while sick, caring for a cohort of influenza patients, he says. Hospitals also need to consider who would get limited supplies of vaccines — how much would go to vulnerable patients and how much to health care workers.

"I think health care systems, as they do their pandemic planning, need to consider what staffing is required for effective patient care," Schwartz says. "If supplies of antivirals or vaccines are so severely limited that they would not be available for all health care workers, then health care systems need to be able to use what is available most effectively to maintain the essential functions."

Hospitals already should be engaging in some preparedness functions, such as educating employees about influenza, the threat of a pandemic, and the importance of vaccination.

"Every year’s influenza vaccination campaign can be thought of as a drill for what would happen with pandemic influenza," Schaffner notes. "The better, more efficient we make our routine influenza vaccination campaigns, the more prepared we will be in an emergent situation."

With an effective campaign, "everyone knows what to do. We all know how much vaccine to order, [and] how many needles and syringes we need," he says.

Vanderbilt also conducted two major drills testing the response to an outbreak. That came in handy when the hospital experienced a surge of influenza patients last year. "We quickly discovered that we had a backup in the emergency room," Schaffner points out. "We moved into our emergency planning mode phase I."

Chiefs of service were able to discharge patients to create more room for the onslaught of patients. The hospital did not need to go to phase II, which involves creating a special ward for the outbreak patients. "We were so pleased we had that plan in place and had drilled it," he adds. "It worked very well."