A Place at the Table

     From the beginning, the medical and research communities have been divided on whether avian flu would be the next big pandemic. And although it now appears that avian flu cases are occurring less frequently, it is clear that historically and statistically, we are due for such a pandemic in the next 5-10 years. For this reason, planning for a potential pandemic should continue, and it's important that fire and EMS services become active participants in planning for their communities. Your department should have a seat at the table. This article is designed to assist you in preparing your department for this role. It offers talking/discussion points and information for active participation in a successful planning process.

     First, it is important that your department have plans in place to take to the discussion table. There should be a designated member of the department charged with establishing the plan and educational activities to support it. The designated officer for infection control (DOIC) is ideal for this role. The DOIC has been trained in disease-transmission issues and established a working relationship with local medical facilities and the public-health department. The DOIC should also already have in place a working communication system for disease reporting and information sharing. The DOIC has resources for tracking information on disease issues and should have an established network with other DOICs in the area. Using the DOIC as your representative will not require the investment of additional resources and education to bring another person in the department into a similar role.

     Second, ensure that your department has its own plan before taking on discussions and recommendations in a group. The group may ask you for suggestions. The checklist sheets found at www.pandemicflu.gov are useful tools in the planning process. The specific checklist for emergency medical services and transport agencies provides a detailed guide. Download it and establish where your agency is now. The checklists all begin with having one individual designated to run the response program.

     Third, begin an evaluation and education program. You will need to consider the emotional reaction and potential for fear among your fellow providers if and when a pandemic occurs. During the 1918 Spanish flu pandemic, 25% of fire and police employees did not report for duty. One reason was fear of contracting the disease; another was concern for family members. Even the best-looking plan on paper will fail if these issues aren't addressed. Lessons can be learned from the way Hong Kong officials dealt with SARS: It was established that education was critical and had a direct bearing on employees' attitudes toward working. The government set up education and training programs for the employees and kept the population informed as well. Education was, and should be, two-pronged: for staff and for the public. Here is the Hong Kong approach:

Public Education
     The Hong Kong Department of Health prepared ongoing informational booklets for the public. These kept the population up to date on the outbreak and gave them instructions for personal protection. The government set up practice drills for a high-case-rate event in which the public also participated. This is not currently being done in this country, but could be a key component of reducing fear and panic in the public. The U.S. has some areas that have had practice drills, but they've asked for volunteers. That is not the same as using the community at large. A mass panic situation would have disastrous results. Why can't the public know and practice reporting to points of distribution (PODs)? This may be a key point in planning discussions. A CDC survey conducted during smallpox response planning found that 25% of the population surveyed would not report to a POD, but would seek treatment/medication elsewhere. This could have a major impact on control and response.

Staff Education
     In Hong Kong, education and training were provided for emergency medical personnel, and their fears and concerns were assessed. Generally, their commitment to work depended on how safe they felt their family was. The medical community and government of Hong Kong set up phones so that medical personnel could maintain direct links to their families. Child care issues and personal preparedness were also concerns. The website pandemicflu.gov also provides a checklist for personal family planning.

     In a survey of 100 physicians by the American Medical Association, 80% said they would care for infected patients, and 40% said they'd work even if they were at risk for infection. What are the views of your workforce? Your staff's attitudes and needs should be established to formulate an effective plan and meaningful education program.

     Education and training will need to be ongoing as information and case rates change. Consider a daily or weekly bulletin to keep staff current and informed. Years ago, the public drilled for a possible nuclear attack. The same approach could be useful in pandemic planning/preparation. It appeared to work well in Hong Kong.

     Fourth, reports suggest there may not be enough vaccine for the pandemic strain, and it also appears that there will not be enough antiviral drugs. Adequate doses should be available in about 2008. Therefore, isolation of infected persons or quarantine of the exposed may be the only approach open to you. It should be a focal point of your planning and education. This approach has proved successful for centuries. If there is to be isolation and quarantine in your area-with roads shut down and no entry or exit-the public must be aware so they can plan appropriately. Suggest a survey of local residents to obtain data on how they might cooperate with an ordered quarantine and/or isolation. Suggest supplying the public with commonsense lists of food and medication needs.

     Fifth, work in the group to ensure that any approach is evidence-based. Science should prevail, not fear and emotion. This approach will be cost-effective as well. Many companies offer items for pandemic protection that are not needed or recommended, but are very costly. Companies may use fear to sell products. Become familiar with what's out there and bring this information to the attention of the planning group. For example, no special cleaning agent is needed or recommended for avian flu, but there are companies selling special agents to kill it!

     Sixth, encourage annual flu vaccine programs and a plan to address rationing, supply and distribution. The CDC issued new recommendations for annual flu vaccine programs this past February. For healthcare employers, the document is essentially a mandate for free flu shots for employees. It also clearly states that if a healthcare worker chooses not to be vaccinated, they must sign a form saying so. The new guidelines also expand the risk groups for early vaccination to infants, pregnant women and others. Knowing the rationale for these guidelines is key to understanding the importance of this program.

     Each year the vaccine contains three strains of flu virus predicted to be the leading causes of illness for that year. The three strains include two type A viruses and one type B virus. It is predicted that a pandemic flu would be a type A virus. The concern is that an individual infected with a normal type A flu virus might become coinfected with a pandemic flu virus, and the two would come together to form a new virus that we might not have anything available to combat. This is a part of the rationale for, and increased emphasis on, annual flu vaccine programs.

     Ensuring that annual flu vaccine programs are available to citizens should be part of communities' overall pandemic planning. A second reason for promoting these programs is to reduce employee illness and replacement costs. For members of the healthcare team, this is also being viewed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as a patient-safety issue.

     In a recent conference presentation at the Association for Professionals in Infection Control and Epidemiology (APIC) conference in Tampa, Dr. Gregory Poland from the Mayo Clinic cited six lawsuits filed by patients who acquired the flu from healthcare workers who were working when ill. Poland also stated that flu is the sixth-leading cause of death in adults in the United States. Annual flu shots are now the standard of care, and all employers of healthcare workers need to be aware of these issues and address them.

     Finally, the CDC published work-restriction guidelines in 1998. These guidelines list when employees who are ill can and cannot work due to their illness. The Occupational Safety and Health Administration (OSHA) is enforcing these guidelines. Such restrictions protect both coworkers and patients. Every department and healthcare entity should implement and observe these guidelines. They can be found as an appendix to OSHA's CPL 2-2.69, dated November 27, 2001. Compliance with these guidelines will be important in a flu outbreak or pandemic.

Maintaining Medication Supplies
     Currently, the government recommends individuals keep extra supplies of their prescription medications on hand to sustain them through an emergency like an avian flu pandemic. It is important to know, and be sure that others know, that there has not been discussion or agreement with insurance companies underlying this policy. The Centers for Disease Control and Prevention (CDC) only recently announced that it is in discussion with a couple of insurance groups. One has stated that it will place a limit on such requests. This presents a problem in planning. How might needed medications be obtained and paid for if insurance companies will not authorize payment? One suggestion is that extra medications could be purchased without going through an insurance company, if one can afford it. This is a very important aspect for both family and workplace planning.

Bibliography
Avian flu challenges: Act now to create communicable illness policies. Minnesota Business, Feb 2006.
Centers for Disease Control and Prevention. Guidelines for Infection Control in Hospital Personnel, Oct 1983.
Centers for Disease Control and Prevention. Influenza vaccination of health-care personnel. MMWR, Feb 24, 2006.
H5N1 Avian Flu Virus Vaccine Induces Immune Response in Healthy Adults. NIH News, Mar 29, 2006.
Holly SA. Use of an Annual Influenza Vaccination Campaign to Test Bioemergency Preparedness. Oral abstract presentation, APIC 2006.
Occupational Safety and Health Administration. CPL 2-2.69, Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens, Nov 27, 2001.
Yung R. Hong Kong's Response to Emerging Infectious Disease-A New Millennium. Centre for Health Protection, Department of Health, Kowloon, Hong Kong.

Katherine H. West, BSN, MSEd, CIC, has worked in the field of infection control since 1975. She lectures both nationally and internationally on this topic. She was recently voted a "Hero in Infection Control & Prevention" for 2006 by the Association for Professionals in Infection Control and Epidemiology for her work in the field of infection control and EMS.