BY MIKE McEVOY
First identified in California, Texas, and Mexico during April 2009, swine flu continues to stress government, health care, and public safety resources. As entire nations illogically began slaughtering their pig populations, the virus was quickly renamed the 2009 H1N1 influenza. Within weeks of appearing, the virus swept across every continent. In North America, H1N1 skipped the normal summer vacation taken by flu viruses, continually producing low levels of illness that lasted into our current flu season. Thus far, H1N1 appears to have outdone its competition and has become the dominant seasonal influenza virus. H1N1 lessons have been many, and there are likely more to come. If we can profit from our experience, the future may call these “lessons learned.”
The realization that a novel virus potentially capable of producing significant illness appeared virtually overnight in the United States highlighted a significant flaw in virtually all pandemic plans: opportunity to prepare. Past experience with severe acute respiratory syndrome (SARS) and avian flu tricked pandemic planners in North America into thinking that any future outbreak would likely begin in Europe or Asia and then slowly spread to our hemisphere. Plans in the United States were predicated on early warning and weeks of opportunity to ramp up surveillance and supply inventories.
As though it wasn’t enough to be caught with our pants down in planning, H1N1 quickly posed another unaccounted-for challenge: severity. Following the lead of the World Health Organization (WHO), nearly all pandemic plans escalated activities based on mortality. While H1N1 spread swiftly, it quickly became obvious that the majority of victims did not die. We now estimate the mortality from H1N1 to be only one-eighth that of seasonal influenza; plans predicated on death rates proved woefully off base. WHO’s quick escalation to declare H1N1 a full-blown pandemic seemed appropriate, based on how quickly and easily the virus spread. Yet, WHO-recommended government and public health responses1 such as closing borders, prohibiting public gatherings, placing suspected cases under quarantine, and shuttering schools and churches made little sense for an outbreak that produced so few deaths.
Logic led most government, healthcare, and public safety leaders not to overreact to what was commonly referred to as a “continually evolving situation.” However, lack of comprehensive systems to monitor the spread of H1N1 and its effects on the population led to vastly different approaches in its management, and this diversity continues today. For example, there was an early presumption that H1N1 was transmitted by respiratory secretions; the Centers for Disease Control and Prevention (CDC) suggested health-care workers caring for suspected or confirmed cases use N-95 masks. Although the mechanism of transmission was not completely validated, use of high-level respiratory protection for a virus less serious than seasonal flu made little sense to many state health officials, who advised workers in their states that simple surgical masks were sufficient protection. Despite published evidence demonstrating simple surgical masks are comparable to N-95s,2 the feds have yet to back down, most likely because of political pressure. This is but one example of confusion created by conflicts between science and public health guidelines.
SOME DIFFICULTIES
Ultimately, our style of government lends itself to a lack of leadership when confronted with a national public health emergency. The CDC has expert resources, sophisticated laboratory facilities, and large stockpiles of medications and supplies, but definitive authority for decisions rest with each state and, in many cases, at the local level. Without comparable expertise and often operating in a vacuum, state and local officials are often stymied when difficult decisions need to be made. Consequently, deciding how to allocate and distribute limited supplies of vaccine, whether to use or not to use antiviral medications, how to best care for critically ill patients, which adjustments should be made in EMS responses, and other determinations are often made at the point of care instead of using a comprehensive approach. Thus far with H1N1, the results have been wide variations in practice; lack of ability to evaluate and disseminate best practices; and great disparities between larger, more sophisticated systems and their smaller, less funded counterparts.
Inadequate supplies proved to be a universal problem for both health care and public safety. By October 2009, suppliers of N-95 masks and alcohol-based hand gels were seriously backordered. Many hospitals and public safety agencies found their own stocks depleted and, unable to obtain replenishments from their usual suppliers, were forced to make requests of state and federal stockpiles to continue operations. Given the abundance of pandemic planning tools available, our history of SARS and ramped-up preparatory efforts for avian flu, lack of personal protective equipment (PPE) is nothing less than poor planning. There can be no doubt that future outbreaks will overburden our supply chain in exactly the same fashion as SARS and H1N1; proper preparedness mandates that every department and organization maintain stockpiles to carry them through a PPE supplier shortage.
Poor communication has hampered the CDC’s ability to monitor the H1N1 situation as well as to disseminate information to clinicians and public health officials. There are no real time systems available to measure illness patterns across the United States. Although testing to differentiate H1N1 from seasonal flu illnesses was initially recommended, the virus became the predominant flu throughout the world, so there was little sense to continue testing for the obvious, especially since no special treatments that depended on test results were available.
The decline in testing has relegated many public health officials to monitoring cold and flu remedy sales at local pharmacies or flu-like illness visits at medical offices and emergency departments. Despite many well-designed and very current technologies, including Web casts, e-mail, Twitter, Facebook, and text messaging, the CDC remains unable to reach the majority of health-care providers across the country. State, county, and local health offices don’t do much better. One of the best resources for information is a site the CDC established that collates all updates made to the multiple government influenza sites into a one-stop source for updates (www.cdc.gov/h1n1flu/whatsnew.htm). This site has been poorly publicized; the official stance of the federal government is to direct inquiries to the www.flu.gov site, which is nice for the general public but falls short of emergency responder needs.
A significant consequence of poor communication was failure to realize that, despite the apparent widespread nature of H1N1, outbreaks have largely been regionalized. The tremendous number of cases experienced in New York City during the spring were, for example, limited to New York City and did not spread throughout the rest of New York State. Media hype coupled with lack of timely and accurate case tracking and reporting led most people to believe that significant numbers of cases were widely distributed. H1N1, like most influenza viruses, continues to spread worldwide; but when large numbers of cases occur, the outbreaks still tend to be regional in nature. As New York City realized during the fall, herd immunity conferred by previous spring outbreak helped avoid a repeat performance of widespread H1N1 during the traditional flu season.
Filtering information to street-level firefighters and medics has been confounded by the confusion above them. More than ever before, department chiefs and medical advisors have found it necessary to provide succinct, reliable, and up-to-date information to their members. Many have been unable to filter through the voluminous e-mails, Web sites, and advisories and pass on clear and concise information to their members. This is a challenge for the future. Private industry has also been largely isolated from regular communications with public safety and public health. Because private industry operates much of our critical infrastructure, including communications, utilities, and transportation, and because their continued existence relies on continuity of operations, they have developed their own pandemic plans. You may be startled to learn that private industry, in many cases, is leaps and bounds ahead of the public sector in pandemic preparedness. Unlike many hospitals and municipal agencies, few private sector businesses were caught without adequate stockpiles of pandemic supplies including PPE for their employees.
A repeat issue for emergency responders, affecting health-care workers in general, was (and in all likelihood will continue to be) the failure to use appropriate PPE. During the SARS outbreak, the EMS system in Toronto was crippled by unprotected provider exposures.3 The situation was so troubling to the CDC that it issued the first ever Emergency Medical Services advisory.4 Flash forward to 2009, and you probably read media reports that 15 percent of the Tasmania, Australia, ambulance service was placed in isolation following unprotected exposures to H1N1-infected patients. An Australian official told the press, “If people don’t take it seriously, this sort of thing will happen ….” To shed light on why health-care workers infected with H1N1 had failed to use recommended PPE, the CDC compiled several insightful studies.5 There are lessons in the five root causes discovered:
- 1. A belief that PPE is not necessary, is inconvenient, or is disruptive.
- 2. The lack of the availability of PPE.
- 3. Inadequate training in infection control.
- 4. The lack of a systematic approach to infection-control safety.
- 5. The failure to recognize the need for PPE (situational awareness).
In many situations, there may be more than one cause for EMS provider failure to use PPE. Now, and going forward, company officers, medical directors, and chiefs need to seriously consider how to improve compliance with use of appropriate PPE. These root causes provide a starting point for some serious internal analysis.
Finally, but by no means the last lesson, efforts to push out vaccines produced major headaches. To begin with, it takes four to six months to produce a new vaccine. The more lead time before an infection begins to spread rapidly, the better the opportunity to protect the population with a vaccine. Had epidemiologists paid closer attention to pigs, it is highly likely that the mutation responsible for the human H1N1 virus might have been detected before it had a chance to cause human illness. Until now, international surveillance of pigs has been weak at best, despite a long-standing suspicion that pigs could hold the key to mutations that allow normally species-specific viruses to jump between species. Closer observation of pig populations on an international scale could be a valuable early warning tool for predicting and preventing future pandemics.
VACCINES
The vaccines themselves created plenty of hullabaloos. There are more than 25 vaccine-preventable diseases in the United States.6 Although vaccines have slashed death rates, more than 90,000 Americans continue to die each year from these diseases. Influenza kills roughly 36,000 people annually, most of them ages 65 years and older. For reasons not well understood, annual flu vaccinations lower death rates from all causes, not just the flu: Get a flu vaccine in the fall, and you are half as likely to die during the winter from any cause than people who don’t get the vaccine.7
The same holds true for health-care workers: When they receive annual flu vaccines, their patients are less likely to die. In the battle against flu, vaccinations are irrefutably the best tactic we have to limit spread of the virus in our communities; no other intervention comes close to the effectiveness of flu vaccines.8 Quite obviously, from the many studies done in community and health-care settings, unvaccinated people have the ability to spread the flu virus to others even without becoming ill themselves. To protect patients, families, and loved ones of health-care workers and their communities, many employers have for years required annual flu vaccination as a condition of employment for health-care workers.
The Joint Commission that accredits hospitals and nursing homes in the United States has insisted for two years that employers bend over backward to offer health-care workers flu shots. In New York State, despite herculean efforts, only 40 percent of healthcare workers were vaccinated during the 2008-2009 flu season, a rate only slightly better than the general public. Believing that patient safety and lives were on the line, especially with the additional strain of H1N1, New York decided that it could ask only so many times for health-care workers to make responsible choices. An emergency state regulation was issued to mandate cooperation. Since it was subsequently lifted because of vaccine shortages, it is quite likely that other states and even the federal government will take similar actions in the future. Think about it: Seat belts save lives; until their use became mandatory, however, most people didn’t put them on.
Arguments over vaccination continue and likely will into the future. During a pandemic that is actively threatening the lives of the most vulnerable members of our society (the very young and weak), we are obliged to use every weapon at hand. Until better tools to combat the spread of infectious diseases become available, vaccines remain the ultimate weapon in our battle to protect the public.
The H1N1 pandemic has not resulted in mass fatalities, pandemonium, or widespread disruption of society. It has put a tremendous strain on our healthcare system, some regions more so than others. Many opportunities for improvement became evident from international to local levels and extending into our own homes and families. As with past outbreaks, H1N1 reminded all of us that complacency has a price and, depending on what Mother Nature throws at us next, that cost is significant enough for us to closely examine our responses during the current flu season and turn the lessons into lessons learned.
References
1. “Phases 5-6 Pandemic,”World Health Organization. 2008. www.who.int/csr/disease/influenza/extract_PIPGuidance09_phase5_6.pdf (accessed October 29, 2009).
2. Loeb, Mark; Nancy Dafoe; James Mahoney; John Michael; Alicia Sarabia; and Verne Glavin, “Surgical Mask vs N95 Respirator for Preventing Influenza Among Health Care Workers: A Randomized Trial,” Journal of the American Medical Association, Oct. 2009:E1-E7.
3. Silverman, Alexis; Andrew Simor; and Mona R Loufty, “Toronto Emergency Medical Services and SARS [letter],” Emerging Infectious Diseases (Centers for Disease Control), Sept 2004.
4. Updated Interim Guidance: Pre-Hospital Emergency Medical Care and Ground Transport of Suspected Severe Acute Respiratory Syndrome Patients. April 3, 2003. http://www.cdc.gov/ncidod/sars/emtguidance.htm (accessed October 30, 2009).
5. “Novel Influenza A (H1N1) Virus Infections Among Health-Care Personnel – United States, April-May 2009,” June 2009; MMWR 58(23), 641-645.
6. “Vaccine Preventable Disease Listing.” 2009. http://www.cdc.gov/vaccines/vpd-vac/vpd-list.htm (accessed October 30, 2009).
7. Kwong, Jeffrey C; Terese A Stukel; Jenny Lim; Allison J McGeer; and Ross E Upshur, “The Effect of Universal Influenza Immunization on Mortality and Health Care Use,” 2008; PLoS Medicine 5(10),1440-1452.
8. “Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009.” MMWR, July 2009; 1-52.
You may be startled to learn that private industry, in many cases, is leaps and bounds ahead of the public sector in pandemic preparedness.
MIKE McEVOY is the EMS coordinator for Saratoga County, New York, and the EMS technical editor for Fire Engineering. He is a nurse clinician in the cardiac surgical ICUs at Albany Medical Center and teaches critical care medicine at Albany Medical College in New York. He is a firefighter/paramedic and chief medical officer for West Crescent (NY) Fire Department. He is a pandemic consultant to several major corporations, critical infrastructure businesses, and governments.
