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We have ended a week of intense planning, logistical, and communication glory. There have been media reports 24 hours a day, reviewing many angles of a worldwide effort to prevent death and disability. We are clearly missing a “body count”, but are just seeing the beginning of the spreading map that shows how a small traveler can reproduce itself across every time zone and continent on the planet. All in a week!
 
Without a body count, what relevance does this outbreak of influenza A/H1N1 of swine origin have? There is an ongoing threat on infectious diseases, and likely always will be.  With the world’s new transportation systems, any variant, virulent respiratory virus will be spread in global fashion in rapid course.

With the world’s new communication systems, information is spread even more rapidly, and the hype of the media has tremendous effect on large populations, and can dramatically affect people’s behavior.  If the information is timely, correct, and consistent, there is great value to the communication system.


"Perhaps this week’s activities were 'the sentinel bleed' that will allow us to develop plans, tools, test, and vaccines that save millions of lives this fall.  It would be brilliant to use this opportunity to completely develop those items, knowing that at some point they will likely be useful."


Diseases don’t need a body count to produce population change, at least not yet.  But how many more global alerts before we mute the response, the issue of “crying wolf” that becomes ever more important in the world of digital 24 hour media.  We should all remember that the last variant virulent respiratory virus (SARS in 2003) had its greatest mortality and effect on our own industry, as health care providers suffered the greatest losses in that outbreak.
Pandemic flu planning has been occurring over the last 7 years or so, involving essentially every health planner in the country, and many clinicians.  I have been one of them.  Interestingly, after many hours of planning, and drafts of documents, and binders of materials, the Pandemic Flu plans look pretty anemic.  It took about 5 minutes of reading the plans early this week to identify tremendous holes in preparedness, and lack of specificity in the responses, and failure to identify the logistics.  And yesterday we finally were able to put a legitimate process document out to our emergency providers that could direct their actions and response to flu victims.

What if this coming week sees the little virus go away.  No body count.  More people died of xxx this week in yyy city then died of this virus across the globe.  What is the relevance? 

In a week of intense activity, we did communicate effectively with each other.  The pandemic flu plans in every state and community got pulled off the shelves, and updated in a way that would not have been possible.  We reminded everyone in the world of the importance of handwashing with soap; cover your mouth; and stay home when you are sick.  Maybe those 3 items alone will save a million infections over the next few months, until the message wears away.

There are some very important needs that have not been addressed.  We need better stuff, and clear instructions on use that are reasonable and cost-effective:
  • Are we to use N-95 masks, and do they really need to be fit tested?  Many public health and infectious disease authorities felt the masks could be used safely and effectively without fit testing.  We have not come to guidance on how long the masks can be used in one work interval, what conditions will require them to be removed and replaced, and how they can be made more comfortable for the wearer.  There are new models of N-95 (and higher) masks, with higher costs.  Are they needed and worthwhile?
  • Do we need gowns for all patient interactions, just the ones generating droplets, or should they be replaced with disposable suits?  Gowns are hot and uncomfortable and again, cost money.  What conditions make them effective?
  • Do nebulizer treatments generate an infection risk for emergency staff?  Should we be using subcutaneous epinephrine as a substitute, and what clinical effect would that have?
  • How can we make a rationale, efficient, and timely diagnosis of the dangerous disease?  Testing kits are not available for the A/H1N1 virus, and some clinical strategies had to be applied until the definitive test results came back days later.  This poses problems in isolating the index patient, and then applying quarantine to that person’s families and/or acquaintances.
  • Vaccine.  Technology is helping.  Each of these episodes seems to help the science leap ahead. 
There were a lot of policy decisions that were made in a flurry of multidisciplinary meetings in my region, and probably in yours.  At these meetings, and with significant perceived risks coming quickly, leaders had to make decisions to crystallize a lot of nebulous guidance that was developed in years of Pan Flu meetings.
  • Do employees get paid if they are asked to stay at home, or sent home ill, or both?
  • What will be quarantine criteria and intervals?
  • Who can order isolation and enforce it?
  • Who should get the rationed doses of antiviral agents (Wow, did that cause some feelings to get hurt in some people.  And some other people have great new bargaining chips as their position was on the “must protect” list).
  • How can we get our employees to come to work, and act and feel safe?
There is a very real possibility that this week’s breakout could fizzle out, with no significant loss of life or widespread serious illness.  If so, there is a very real risk that the same virus in more dangerous form may breakout in the fall.  That pattern has happened before in some of our worst pandemic episodes.  Perhaps this week’s activities were “the sentinel bleed” that will allow us to develop plans, tools, test, and vaccines that save millions of lives this fall.  It would be brilliant to use this opportunity to completely develop those items, knowing that at some point they will likely be useful.

But this episode, in one week, was one of the greatest opportunities we have had to show our employees how important they are, and how much we will work to protect their health.  Through the many risks that are part of day to day emergency care (MRSA, Tb, C. difficile, and so on), our most important decisions should be based on developing processes that improve the care of our patients.  In outbreaks of dangerous diseases, those patients won’t get great care if our employees are afraid to come to work.  In our everyday activity, and with even greater dedication during outbreaks, we need to commit to our staffs that we will protect their lives and their families.

We have done that in one busy week.  Let’s communicate that to our industry.

 
 

Comments   

# Swine fluconcerned doc 2009-05-06 18:30
You note that this week you have shown employees how important they are and their health is protected. How have you done that? If this virus mutates into a potentially more virulent and deadly one come the next flu season, what measures are in place to separate patient populations from the get-go such that other patients in the waiting area don't get infected. What measures are in place such that the nurses, physicians, EMS workers and laboratory personnel and so forth are protected? I don't believe these questions are adequately answered. In Mexico, the ICU in which one of the first patients died was infected. That is, all the other patients and 16 staff members also got the h1n1 virus. The hospital was closed. What measures are we taking to protect health care workers, as they are integral to protecting the health of the population?
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