A deadly flu strain. Ease of contamination. Mass casualties. Sounds like a Dark Ages doomsday tale to most people, but to the infection prevention and control community, this scene is a reality that requires preparation. An influenza pandemic is just as possible as ever before, and occurs when people have little or no immunity to a new influenza virus, and when no vaccine exists. A pandemic flu can navigate the globe with alarming speed.
No one knows when the next influenza pandemic will occur, but experts say were overdue. Fallout can range from a halt in school, business and transportation services, all the way to mandatory isolation in peoples homes.
The 1918 influenza pandemic was responsible for more than 500,000 deaths in the United States, and the pandemics of 1957 and 1968 killed 70,000 and 34,000 people, respectively.¹ Experts believe pandemic events will happen in one to three waves, each lasting eight to 12 weeks.¹ Healthcare professionals absolutely need to take the threat of infectious disease seriously, says Shelly Sikes Diaz, a spokeswoman for the Centers for Disease Control and Prevention (CDC).
Neither SARS nor avian flu is an immediate threat in the U.S., but that doesnt mean that healthcare professionals can relax, Sikes Diaz says. Now is the time for everyone to prepare for avian flu. By preparing for avian flu, we are preparing ourselves for almost any emerging infection.
Most healthcare staffs are working hard to prepare for pandemic events, says Terri Rebmann, PhD, RN, CIC, associate director for curricular affairs, and assistant professor at the Institute for Biosecurity at Saint Louis Universitys School of Public Health. She is also a member of the disaster preparedness committee for the Association for Professionals in Infection Control and Epidemiology (APIC).
My impression is that theyre doing as much as they can given the limitations and the challenges of disaster planning, Rebmann says. Theres not a lot of funding.
The good news is that healthcare staffs may have more warning time for pandemic influenza than for natural disasters or terrorist events. However, pandemic events are highly uncertain and plans to deal with them must therefore be flexible.
Avian influenza also known as bird flu is caused by type A influenza viruses that infect wild birds and domestic poultry. Some avian influenzas are worse than others. Low pathogenic avian influenza virus H5 and H7 strains are closely monitored because they can mutate into highly pathogenic avian influenza. Highly pathogenic avian influenza of the H5N1 strain is rapidly spreading in birds in some parts of the world and is one of the few avian influenza viruses that infect humans. Most cases resulted from contact with infected poultry or their secretations/excrement.¹
The threat of avian influenza is indeed real, says Darlene Sparks Washington, DPM, director for preparedness and team leader for influenza pandemic planning for the American Red Cross.
Domestically, the greater concern is that the virus H5N1 that causes avian influenza will mutate to become a threat to humans and able to spread effectively from human-to-human, Sparks Washington says. This would create a novel virus, one to which there would be limited to no human resistance and could grow to pandemic proportions.
We have noticed fewer headlines related to pandemic flu, which means that public attention and interest tends to decline, Sparks Washington says.
This can create barriers and challenges in our ability to get the public to personalize the risk of a flu pandemic happening and taking action to prepare.
H5NI is indeed on top of the concern list, but unfortunately, its a long list.
Other Trouble Makers
There are three types of influenza viruses: A, B, and C. Only type A influenza viruses cause pandemics. Seasonal influenza outbreaks can be caused by either type A or type B influenza viruses. Influenza type C viruses cause mild illness and do not cause epidemics or pandemics. Only type A is divided into subtypes, and these are based on the presence of two viral surface proteins (antigens): hemagglutinin (H) and neuraminidase (N). To date, 16 hemagglutinin and nine neuraminidase surface proteins have been identified in influenza A viruses.² Anthrax and small pox used to be dominant concerns, but now the focus is on avian flu, SARS and monkey pox, Rebmann says. As for severe acute respiratory syndrome (SARS), there are currently no human cases, but it could reemerge at any point.
(The last outbreak) wasnt that bad in the United States, but some countries had massive impact from that event, Rebmann says. We were extremely lucky in that we had very few cases that came to the United States. The cases that did come to the U.S. were not severely ill and were not some of the super spreaders that were seen in some other countries such as Canada. When we did identify a case of SARS here in the United States all the hospitals and the public health department and the CDC reacted rapidly and instituted very stringent infection control practices that really helped control it.
U.S. healthcare workers were able to learn from other countries that dealt with SARS first. If the United States is going to be ready again next time, its healthcare workers must start with the very basic element of learning how to properly don and remove personal protective equipment (PPE), as that practice was sub par during the last outbreak, Rebmann says.
A successful infection prevention and control program for pandemic influenza uses the same strategies that are used for any infectious agent. These include facility and environmental controls, standard operating procedures, personal protective clothing and equipment, and safe work practices.
Standard precautions should be used for all patients, even if the patient has not been diagnosed with the flu.¹ Standard precautions apply to blood, other body fluids, secretions, excretions, mucous membranes and non-intact skin. Healthcare workers should practice proper hand hygiene before and after contact with patients. This routine includes alcohol-based hand rubs, washing with soap and water and drying with a single-use towel.
Standard operating procedures should also be used in regards to patient care equipment, rooms, soiled linen, spills, treatment of waste and for the prevention of needlestick injuries.¹ Clear and thorough pandemic infection control guidelines are provided by the Occupational Safety and Health Administration (OSHA) at: www.osha.gov/Publications/OSHA_pandemic_health.pdf.
Does Preparation Pay Off?
In general, the healthcare community is better prepared every year for pandemic events, and funds are increasing, Rebmann says.
But that being said its impossible to be (completely) prepared for a large-scale pandemic, she says. If you look at the 1918 Spanish flu, that had such a large impact in terms of morbidity and mortality that even with our much better medical technologies and medications and our better way of taking care of patients, the large impact (a similar threat) would have on a healthcare organization not only locally, but regionally, and on a national basis and around the word is just overwhelming.
Its always worth trying, however.
You never reach that end where you say, Were done. Were completely prepared for anything thats going to hit us, Rebmann says. Its a constantly changing environment because our threats are always changing. It creates job security but it keeps everything very challenging.
One such challenge is that healthcare workers may be stationed in unfamiliar environments such as convention centers, schools or arenas. Facility staffs should form pandemic response committees and members should familiarize staffs with the places where they may end up working. The committee members should empower managers and planners with the authority and resources to make plans, implement training and enforce good practices. The members should also identify deficiencies such as lack of guidelines, staff, etc. They should ensure that individuals are cross trained.
Training for pandemic events is necessary, but it can be difficult to retain a balance between education and over-inundation.
You can only bombard people with information so much, Rebmann says. She recommends that facilities adhere to zero tolerance of infections and says the pervasive culture of safety will prepare people best. Several studies of hospital workers show that employees who perceive a strong commitment to safety at their workplace are more than 2.5 times more likely to comply with universal precautions.³
What Your Staff Must Consider
If healthcare professionals want to take action to prepare against an imminent health issue, they should get a seasonal flu shot, Sikes Diaz says. Seasonal flu kills about 36,000 people a year, but only about 44 percent of healthcare workers get a flu shot, she says.
Another way to prepare for pandemic events is to plan for surge capacities. This means having more beds, airborne infection isolation rooms (for negative pressure), ventilators and most importantly, staff.
The difference between an infectious disease disaster and a regular disaster is that (experts) anticipate that up to 30 percent of the staff may be affected by the outbreak itself, Rebmann says. Thats really going to put a crimp on your healthcare worker surge capacity.
As many staff members as possible should be trained to provide ventilator care. It is also wise to have a contract with a back-up vendor in case the primary vendor runs out of supplies.
Morgues must be able to hold more people, and stringent infection control practices must take place there. A great deal of PPE will be needed for healthcare workers, and they should be aware that standards during a pandemic event may be different than normal. APIC leaders this winter are compiling guidelines that address the re-use of respiratory protection during a disaster, Rebmann says.
If you dont have enough N95 respirators to follow the standard protocol (which is use it once, throw it away, get a new one) then were giving them guidelines as far as how can you safely re-use that respirator, she says. For a long time people said, Well stockpile and be fine, but I think people are starting to see that thats just not feasible. If you dont give people guidelines as far as the most protective actions to take, theyll come up with their own ideas and thats not what we want them to do.
Fortunately, there is a lot of information available to help healthcare facilities prepare, and work is being done in the community at large, Sparks Washington says.
American Red Cross employees and volunteers are working with the general public by advising the following:
- Cover your mouth and nose when you sneeze and cough
- Wash hands frequently and properly
- Use alcohol-based hand sanitizers when soap and water are not available
- Avoid touching your eyes, nose and mouth
In addition, we are encouraging the public to prepare for the possibility that there will be movement restrictions to store food, water, medications and other disaster supplies, Sparks Washington says. We are also encouraging the public to talk with their employers and their childrens schools or daycare centers about the plans that they have in place. We want people to think about what could happen and prepare to the best of their ability.
Indeed, education across the board is vital and starts with the basics, Rebmann shares.
We really do need to beef up and educate people about infection control now, she says. Its not just the hand washing. Its about how you put a respirator on correctly and check the fit and take it off correctly. That seems to be one of the big problems with the SARS outbreak (healthcare workers were removing respirators incorrectly, which led to cross-contamination).
Theres a lack of awareness among healthcare professionals and the public, she adds, and it should be addressed now.
Ethical standards of care will be even more important than usual in a pandemic event. APICs emergency preparedness committee conducted a survey recently and found that very few healthcare facilities are including their ethics committees in their pandemic plans. Thats a problem. For instance, what is a healthcare worker to do when several patients need ventilation but not enough ventilators are available?
We have standard procedures of when you put someone on a ventilator, but those arent going to be feasible in the middle of a disaster, Rebmann says. There just wont be enough ventilators to go around. If the ethics committees does not become involved to help make these decisions ahead of time, the fear is that its going to put healthcare providers in a very awkward situation.
All those decisions have to be made ahead of time.
Its very complicated for a physician who is looking at a patient to make that decision, and they shouldnt have to, Rebmann says. Its much better if the ethics committees get together beforehand and develop algorithms about what youre going to do when you have limited ventilators. Its something should be communicated to the community ahead of time (so theyll understand the guidelines).
Americans continue to work on preparedness for all types of disasters and pandemic events are no exception, but more needs to be done, Sparks Washington says.
Although the Red Cross works daily to get America better prepared and the majority of the public knows that its a good idea to be prepared for disasters and other events less than 10 percent of the public have actually taken the three steps to Be Red Cross Ready, Sparks Washington says. This includes getting a kit, making plans and being informed.
Indeed, during a pandemic conditions in the public will influence conditions in hospitals, and vice versa. Therefore, everyone must work together.
APIC is expected this winter to release guidelines concerning infection control practices at disaster shelters.
What we realize from talking to (infection control practitioners) is that there really are a lot of documents out there of how to set up a shelter and run a shelter, but within those theres no infection control guidance to speak of, and the CDC guidance for shelter and evacuation centers is very brief, so weve developed evidence-based practices and posters, Rebmann says.
This is partly in response to the food and airborne infections that broke out after Hurricane Katrina. When you have all those people crammed into little tiny spaces, youre just asking for an outbreak, Rebmann says.
One outbreak can lead to international tragedy, but with good planning on the part of the infection control community and beyond, such tragedy can be minimized.