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 years 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 need 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 burdon on the system and to reduce the points of contact between the sick and the healthy. How do health care institutions provide care where people don’t have to come into the hospital and provide quality service at a reduced cost? It becomes important 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 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. Protocol does not include using connected health technologies. So in advance we need to set up protocals that work that incorporate technology to create order in an otherwise chaotic environment. It is important to educate first responders to 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 repsonse, access to quick testing capabilities, communication materials, etc. The plan itself invisions a robust set of responsabilities 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 – 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 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 moments notice are already prepared and ready to go. A watchboard 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, understanding your vulnerabilities, and updating plans. Test and excercise that plan on a regular basis.
2. Communications and information management are key 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 4 reports per day and told it how it is. 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 smart 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 regulations 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 normally apply to business as usual scenarios.
5. Memorandums of Understanding: Agree in advance of a Pandemic 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 web site to teach you how to structure your organization in a crisis and manage it effectively. Have trigger points that understand in 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 underanticipate the level of stress in a major crisis. Prepare teach the teacher classes in trauma councelling 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 world-wide crisis events. SAHANA is an open-source software application and was used by the Phillipines during the mudslides.
Every tax dollar you spend in 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 a 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, to distribute anti-virals, and to implement plans.
2. Decompress the peak burdon: 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 home, 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 to 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 negligable attack rate. Strategies have to be implemented at a local level.
85% of populations live 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.
Bernard Kershner, Chairman, AAHC Institute for Quality Improvement
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;
Other Pandemic Flu / Avian Flu Video: