On Guard
Nurses across the country work with health departments to put in place a plan of action to battle future flu pandemics
By Scott Williams
January 17, 2005
The Spanish flu that spread across the globe in 1918-19 killed an estimated 20 million to 50 million people worldwide, including at least 500,000 people in the United States.
People wore surgical masks in public to protect themselves from the deadly virus. Sick people flooded hospitals to such a degree that many had to be treated in field hospitals under military tents. Schools closed, business slowed, and some cities reported shortages of coffins, morticians, and gravediggers.
Widespread infection like this throughout a country, a continent, or across the globe is known as a pandemic. It is rarely seen and, almost a century after the Spanish flu pandemic, people have become so confident in modern medicine that they believe another pandemic is impossible.
But experts in communicable diseases say it’s only a matter of time before another pandemic flu strikes. Two others have occurred in the 20th century, including one that many may still remember: The Hong Kong flu of 1968-69 killed nearly 34,000 U.S. residents, while the Asian flu of 1957-58 killed 70,000 in this country.
To prepare for the next pandemic flu, the federal government has put together a national Pandemic Influenza Response and Preparedness Plan, which outlines a coordinated strategy in the event of an influenza pandemic. The plan provides guidance to national, state, and local policy-makers and health departments for public health preparation and response.
Throughout the country, public health officials in each community are developing influenza preparedness and response plans. The idea is for local groups and state governments to coordinate with one another. State governments, in turn, would coordinate with one another and the federal government.
Mona Bedell, RN, MSPH, BSN, a nurse epidemiologist for Denver Public Health, the department responsible for monitoring and dealing with Denver’s communicable disease outbreaks, says the health department has been meeting regularly with county and regional officials. They’re working to develop a plan for handling a flu pandemic and to come up with ways to monitor flu outbreaks, provide vaccines and antiviral medications, and communicate with the public.
She says officials from each county have imagined what might take place in such an event and have designed exercises to test their ability to provide mass vaccinations and communicate with both the public and one another. She says the various health entities have been sharing their plans with one another and coordinating them so that they’re not duplicating one another’s activities.
Bedell says that Denver Health, the hospital that provides medical care to 25% of Denver residents, organized a mass vaccination clinic for employees earlier this year to simulate on a small scale what would happen in the event of a surge in patients. She says the exercise helped identify how many people would be needed to provide mass vaccinations.
“I think that there are many concerns about how to deal with the numbers of people, whether they’re the ‘worried well’ or whether they’re sick and how you organize health care for them,” she says.
Concerns include how to relay information to people of many different cultures, structuring mass vaccination clinics, distributing drugs and vaccines, and designing a plan to make sure there are enough personnel to deal with the sick.
Rob Leeret, RN, nursing operations manager for emergency nursing at Denver Health, says one of the major problems he foresees is determining who is potentially infected with the flu virus and then separating them from patients who come to the hospital for other reasons.
“I think handling the influx of patients 85 and making sure they’re segregated from the get-go [will be important],” he says.
Killer bugs
Experts estimate the next pandemic flu, aided by the ease with which people now travel, will likely kill between 89,000 and 207,000 Americans. Annual U.S. influenza deaths number between 20,000 and 40,000, according to the CDC.
One reason another pandemic flu outbreak is considered inevitable is that it’s impossible to prepare for the virus that would lead to it. In almost every case, the flu virus that circulates each winter is a genetic cousin of a microbe already in circulation. Changes are carefully monitored and a new vaccine is developed each year.
But every once in awhile, a chance fusion and recombination of a human flu virus and a flu virus carried by birds or pigs occurs. The result is a microbe that is easily passed from human to human that has the potential to affect the entire globe. No one is immune to it because there have been no previous infections, and scientists don’t have enough time to develop a vaccine that will prevent widespread transmission.
The first Pandemic Influenza Response and Preparedness plan was drafted in 1978, not long after the swine flu outbreak of 1976. In 1993, the U.S. Working Group on Influenza Pandemic Preparedness and Emergency Response was formed to draft an updated national plan. A draft was released in August and the public could comment for 60 days. Those comments are now being reviewed. The plan will be continually updated to reflect changes in public health, vaccine production, technology, and other developments.
“Our proposed strategy draws upon the wealth of experience and knowledge we have gained in responding to a number of recent public health threats, including SARS and avian influenza,” Tommy Thompson, the former secretary of the U.S. Department of Health and Human Services, said in a press release last year.
“This plan will serve as our road map on how we as a nation, and as a member of the global health community, respond to the next pandemic influenza outbreak, whenever that may be.”
The HHS plan calls for increased surveillance, vaccine development and production, antiviral stockpiling, research, and public health preparedness. The plan describes coordination and decision-making at the national level, gives an overview of key issues, and outlines steps that should be taken at the national, state, and local levels before and during a pandemic. The plan also provides information to health departments and private-sector organizations to help them develop local preparedness plans.
Mary Lopez, RN, MSN, director of critical care, telemetry and dialysis care at Community Regional Medical Center in Fresno, Calif., says many of the measures now being taken in the annual flu season would be implemented in a pandemic flu outbreak.
Those include asking anyone with a cough or runny nose to wear a mask, to make available facial tissues to those who are sick, and to provide bags for discarding used tissues. She says children would be prevented from visiting patients and signs would warn people to be wary of spreading the flu virus.
One issue facing the central part of the state is how to educate a public that speaks 100 different languages. Much of the population is poor and transient, traveling from Mexico to California each year to work in the fields.
Staffing is key
Steve Cantrill, MD, associate director of emergency medicine at Denver Health, says staffing is one of the biggest concerns he sees in handling a pandemic flu outbreak, especially because a vaccine would not be immediately available. Health care workers, therefore, would be exposed to the virus and some would become ill.
Staff morale and fatigue also would become an issue, he says. “Often, medical care providers like to think of themselves as bulletproof,” he says. “We’re not. We need rest periods, too.”
Shortages of equipment, such as ventilators, are likely to occur during a pandemic. Cantrill, however, believes that’s a secondary problem. The main problem will be finding enough respiratory therapists to run them.
“Ventilators don’t come with a respiratory therapist attached,” he says.
Cantrill says Denver Health’s pandemic flu planning has piggybacked on its SARS planning, which, in turn, piggybacked on the bioterrorism planning that took place after the anthrax scare in October 2001. This year’s shortage of flu vaccine has forced hospitals and public health providers to develop communication, rationing, and mass vaccine plans that should help in the event a pandemic flu occurs.
Glennah Trouchet, MD, health officer for Sacramento County in California, agrees, yet she warns that no one really knows how well prepared they are for something like this until it happens.
“We’re much better prepared than we were, say, three years ago, and we’re definitely thinking about it and working on it,” she says. “But if you were to ask me: ‘Are you totally prepared?’ We won’t know that until something hits and then we’ll find out.
“Certainly, we have exercised our communications skills and we have developed contacts with folks that could help us should it be necessary. … Everything that we have done since 2001 has helped us prepare for [pandemic flu].”
Trouchet formed the Northern California Partnership for Influenza Prevention last year that includes the four largest hospital systems in Sacramento County. They meet once a month to discuss issues that might impede the delivery of flu vaccine to the right people.
Alonzo Plough, MD, director and health officer for Seattle and King County Public Health, says pandemic influenza preparedness has become the focal point of all its preparedness planning activity.
“Anywhere we are not obligated to do a smallpox plan, we use pandemic influenza as the model because it actually represents a worst-case scenario,” he says. “If you’re on the road for preparing for an influenza epidemic, you’ll also be well on your way for smallpox or any other communicable disease outbreak.”
Seattle health officials are keeping an eye on the avian flu that has hit Vietnam and China, Plough says, because a lot of people travel between the Pacific Northwest and Southeast Asia.
Plough says although King County, which includes 32 cities and roughly 2 million people, has a plan, that doesn’t mean it has the capacity for dealing with the large number of sick that would result from a pandemic.
He says officials have done some modeling to determine the impact a pandemic flu would have on the area. He says it is estimated that within the first six weeks 1 million people would be infected, 200,000 would become ill, 2,000 would be hospitalized, and 600 would die.
“I would challenge anyone to have the quarantine and clinical capacity to deal with this,” he says.
Plough says hospitals should not be expected to handle all aspects of pandemic flu because they will still have to treat people who with other ailments. Alternative sites will have to be set up in strategic locations. He says as part of the King County plan, officials are getting commitments from gyms, conference centers, and other public facilities promising to serve as alternative sites.
A pandemic will affect more than the health care industry, he says. People will begin staying home whenever possible, major sporting events will be cancelled, and unnecessary public interaction will be discouraged.
In Colorado, a database of retired nurses and physicians is being compiled to allow health officials to “call up” people when they need help, Cantrill says. He says the state has plans to set up trailers that can be converted into 500-bed units in what might be considered the modern equivalent of the tents used during the Spanish flu outbreak.
Denver Health officials have met with the hospital’s engineering staff to come up with a plan for changing the air conditioning system to allow them to vent more areas into the outdoors rather than circulating the air. This would allow them to set up larger isolation areas in order to protect staff.
The threat of bioterrorism, SARS, and the avian flu outbreak have served as a wake-up call for public health officials and public officials, and health care providers hope for the public at large as well.