How Do We Respond to Pandemics and Are We Prepared?

The issue of pandemics is a concern to us all.

The key to looking at pandemic preparation is surveillance. Surveillance has two purposes. The first is to track mutations of existing viral subtypes in order to adjust each year's vaccine preparation, and the second is to search for any new sign of any other mutation of the disease.

Few countries in the world practice adequate surveillance. Public education, coordination among all levels of government, and enabling medical needs to take precedence over moral considerations are all important as well.

It remains to be seen how the policy community, in the US and abroad, will handle this next wave of pandemics.

According to the American Medical Association, nationwide, our hospitals are at 94-96% occupancy. If we were to have another flu epidemic, we would need 197% of our current hospital capacity.

In preparing for a disaster, we need to take advantage of technology to deliver care outside the hospital and in the home to reduce the burden on the system and to reduce the points of contact between the sick and the healthy. How do healthcare institutions provide care where people don’t have to come into the hospital and provide quality service at a reduced cost? It becomes essential to care for patients in a quarantine situation.

Singapore used technology to manage the SARS pandemic with great success. With technology, we can provide care to populations in isolation and reduce the risk of contact between exposed and healthy populations.

When people are in first responder mode, they do not try new things, they go by protocol. The protocol does not include using connected health technologies. So in advance, we need to set up protocols that work that incorporate technology to create order in an otherwise chaotic environment. It is crucial to educate first responders on the value of connected health technologies because when disasters strike, no one wants to think differently. That is not the time to try new technologies.

Communication and planning are critical to reducing the toll a pandemic takes on a community.

Planning: there are 116 tasks in the report signed by the President, including establishing and maintaining anti-viral vaccines and antibiotic stockpiles, medical material gap analysis, sharing scientific information, enhancing public health information and response, access to quick testing capabilities, communication materials, etc. The plan itself envisions a robust set of responsibilities and actions that must be taken at the local and state level to ensure stability and order.

Surveillance: GEIS – a network of department of defense research laboratory facilities around the world to detect local respiratory outbreaks and new strains. ESSENCE – a syndromic-based system that includes 500 sites around the world. The Intelligence community also gathers data.

Response: Make sure someone in a community has the authority to make decisions.

Containment: Preventative measures to ward off an epidemic. Social distancing, such as the closure of schools and other public places, would have the most impact on the person-to-person transmission of the disease. Stockpiling of vaccines is also important.

Communication: At the Department of Defense, communication materials that can be sent out on a moment's notice are already prepared and ready to go. A watch-board system that pulls in data and displays it so people can respond to an epidemic with good, accurate data.

Human nature is somewhat predictable in a crisis, based on stress and the environment, and we can plan for these scenarios.

Resiliency success factors in preparing for a pandemic:

1. Planning makes sense: Do an assessment of your continuity of operations capabilities, understand your vulnerabilities, and update plans. Test and exercise that plan on a regular basis.
2. Communications and information management are critical cornerstones of any plan: If you can’t call for help, you can’t get help. Look for other ways to communicate. If you communicate the truth, stress levels go down because people feel like they are getting an honest picture of what is happening. This happened in New York during 9/11, where Rudy Guiliani gave four daily reports and told it how it was. Tell the truth and tell it often.
3. Organizational stovepipes and silos are detrimental to crisis management: Pandemics will strike through every department you have. If you want to be effective in managing and responding to disasters, share information more effectively between departments during the crisis to accelerate the recovery, minimize the losses and reduce the suffering. Find ways to share.
4. Emergency Powers and Task Orders: Be wise enough to anticipate potential needs and requirements during a crisis. You might want to put in place signed task orders in advance and hold them in abeyance until you need them so you don’t have to go through normal procurement processes in a crisis situation. Customs regulation is a good example. There are numerous examples of aid being donated to a country in need and the customs office putting up roadblocks because of regulations that generally apply to business-as-usual scenarios.
5. Memorandums of Understanding: Agree in advance of a Pandemic on one Web site that will help families reconnect. Get Memorandums of Understanding signed between different departments to share information or to allow doctors to move across state lines. This is a major issue when it comes to HIPAA regulations. Anticipate and get pre-approval.
6. Incident Command System: A free methodology on the FEMA website to teach you how to structure your organization in a crisis and manage it effectively. Have trigger points that understand a pandemic, what to shut down, etc.
7. Simple works better: Don’t use a disaster as a time to experiment with new technologies or new ways of doing things. The people who have to implement your plan are most likely not well-trained.

Stress is key in so many disasters. Don’t under anticipate the level of stress in a major crisis. Prepare to teach the teacher classes in trauma counseling or even initiate television (or WebTV) programming to help people cope.

Many government and NGO agencies will only work with free, open-source software solutions and systems, not proprietary technologies. Many companies, such as IBM and Microsoft, came together to develop open-source software to manage worldwide crisis events. SAHANA is an open-source software application and was used by the Philippines during the mudslides.

Every tax dollar you spend on pre-disaster mitigation and preparedness has a benefit of $4.

What can we do to mitigate the impact of an influenza pandemic before the vaccines arrive?

An influenza pandemic comes in a wave. It spreads rapidly in human populations. From the initial onset in a community to the peak of the disease is a matter of weeks. The rapid taking out of people who become sick and die is enormously incapacitating to the function of communities.

We need to develop strategies to diminish the impact of a pandemic:

1. Delay the disease transmission and outbreak peak: Anything we can do to delay the amount of time before a vaccine peaks buys us time to develop vaccines, distribute anti-virals, and implement plans.
2. Decompress the peak burden: Even if we can’t reduce the number of affected people, if we can decrease the rate at which it transmits, we can preserve the functions of our communities.
3. Decrease the area under the pandemic curve: Decrease the number of people who become sick and die during a pandemic.

Doing simple things, such as closing schools and implementing social distancing policies, and doing them early can diminish the impact of a pandemic on a community. People don’t need to lock themselves in their homes but should judiciously decrease their contact with others.

Ill individuals should voluntarily stay at home for 7-10 days. They are much less likely to transmit disease.

We can target anti-viral treatment for individuals who are ill at home and prophylactic treatment for those who are healthy but staying home with the sick.

By implementing these strategies, we can reduce a 40% attack rate to a virtually negligible attack rate. Strategies have to be implemented at a local level.

85% of the population lives in urban centers. Travel is faster than ever. It takes 1.5 days to go around the world. Mass transportation is ubiquitous in urban centers. A contagious disease has everything working in its favor, which is why many of the ideas outlined above are so important to minimize the impact of a pandemic

The Great Influenza by John Barry is a fascinating book.

Moderator
Bernard Kershner, Chairman, AAHC Institute for Quality Improvement

Panelists

Toby Merlin, MD, Director, Division of Partnerships and Strategic Alliances, National Center for Health Marketing, Centers for Disease Control and Prevention;

Brent Woodworth, Global Operations Manager, Crisis Response Team, IBM;

Joxel Garcia, MD, Senior Vice President, Maximus, Former Deputy Director, Pan American Health Organization (PAHO);

Joseph Kvedar, MD, Director, Partners Telemedicine, Partners, HealthCare;

William Winkenwerder, MD, Assistant Secretary of Defense, Health Affairs, Department of Defense;

Pandemics happen when a disease spreads across a large area, like a whole country or even the world. When this happens, it's important to respond quickly and effectively to try to stop the disease from spreading and to help people who are sick. To respond to a pandemic, governments, organizations and healthcare workers work together to:

1. Control the spread of the disease by finding and isolating people who are sick and making sure people who have been in contact with them are also checked.
2. Treat people who are sick by providing them with medical care and medicine.
3. Educate people about how to stay safe and healthy and how to prevent the disease from spreading.

As for preparedness, different countries have different plans and resources in place to deal with pandemics. Some countries have well-developed healthcare systems and emergency response teams that are trained to handle outbreaks, while others may not have as many resources. It's crucial for countries to continually update and improve their pandemic response plans and to have resources like medicine and protective equipment readily available.