The Emerging Threat of H7N9

Ray Barishansky is a featured speaker at EMS World Expo, September 8–12 in Las Vegas, NV. He will present two sessions: "Are You Ready for the Next Pandemic" and "An Insider's Guide to Publishing and Lecturing in EMS." To register, visit www.emsworldexpo.com.

Here we are in April, and the flu season is rapidly becoming a memory. Looking out for runny noses, unusual coughs and fevers of unknown origin, as well as other influenza-like illnesses (ILIs), traditionally slips to the backs of most EMS providers’ minds sometime in March.

This year, however, something is developing that should give us all pause. Even as you read this, Chinese health authorities, with the assistance of the World Health Organization (WHO) and other experts, are tracking an H7N9 bird flu that has the potential to become a pandemic. As of April 24 there were 108 cases confirmed in China, with 22 deaths. That’s a significant number of deaths for the overall number of cases. In a report from earlier this week, the WHO warned that the H7N9 virus was one of the most lethal doctors and medical investigators had seen in recent years.

For the most part, flu outbreaks like this pop up, then fade within weeks. But occasionally they become pandemics, spreading across the world. What will happen with H7N9 is unclear, but there are things we should know specifically about it, as well as generally about outbreaks like it. This awareness should come from established sources for public health information such as the WHO and Centers for Disease Control and Prevention (CDC), but also from your local and state health departments, as they will likely issue guidance for PPE and in other areas.

Just last year a professor at Northwestern performed research on the predictability of pandemics based on transportation data. He found that cities with very high levels of connectedness, such as New York City, Los Angeles and London, are important epicenters for tracking the spread of diseases, and that when a disease reaches these cities, it is likely to spread far and quickly. The problem thus becomes people from more-infected areas traveling to these larger population centers.

EMS Specifics

One of the only positive elements for EMS providers regarding identification of patients is that H7N9 symptoms are similar to those seen with other flus, including fever and respiratory problems. Thus, as a whole, it will be easy to spot these patients. The bad news, and one of the more troubling elements of this infection, is that one patient, a 4-year-old Beijing boy, was diagnosed with it without having clinical symptoms. He had been tested because health authorities were monitoring a group of high-risk individuals, including some of his family members. The boy has since been hospitalized for observation.

Emergence of an asymptomatic H7N9 case, if confirmed by other official sources, would be a significant development. The implications for EMS are frightening, as asymptomatic patients will be able to pass along infection even while showing no signs or symptoms. This could mean asking all patients who have potentially been exposed to the flu to wear masks, as well as EMS providers themselves utilizing appropriate PPE and protective measures and taking extra caution.

Another noteworthy specific is that the H7 strain of flu hasn’t been identified in humans before. That means we have no residual protection or immunity to the disease, which matters for two reasons: It means this flu could make us sicker, and that any vaccine will probably need more antigen in each dose to be effective. If we need more antigen for each vaccine, that translates into fewer overall vaccines to go around. That may require the CDC to prioritize who will get vaccine once it becomes available, like we experienced at the beginning of the H1N1 pandemic.

The lessons here are many and include:

• Stay in tune with the news. We live in a time where international travel can take a distant disease and place it in your backyard within 24 hours. Read the newspapers and go to reputable websites for information on what might impact you and your EMS agency.

• Don’t let the symptoms get past you. Just because the flu season is over, EMS can’t be careless when examining patients.

• An ounce of prevention works. Remember all your prevention techniques, including use of PPE, washing your hands and using hand sanitizer. Ensure all patients exhibiting symptoms of influenza-like illnesses wear masks. EMS providers should wear gloves as well as surgical masks when treating these patients. Decontaminate your ambulances, stretcher straps, ceiling handrails, door handles, driver’s compartment surfaces, portable and fixed O₂ tanks, stair chairs, jump kits, computers and clipboards as often as possible.

To quote flu expert Michael Osterholm, PhD, “Every day without a pandemic is another day to prepare for it.” That is possibly the most important lesson here, so take the time to get ready. This means interacting with your local public health authorities, reviewing your agency’s pandemic preparedness plan and stocking up on PPE.

Conclusion

There are several ways this current situation could resolve: The number of human cases of H7N9 could dwindle, and we could forget all about it. That could mean it’s gone, or it might just be “smoldering”—showing up in animals and people every once in a while, and possibly evolving into a pandemic someday (or not). On the other hand, the virus could evolve to spread easily from person to person, unleashing a pandemic in a matter of weeks. At this point, there’s no way to know for sure. But as Louis Pasteur said, “Chance favors only the prepared mind.”

Raphael M. Barishansky, MPH, is director of EMS for the Connecticut Department of Public Health. A frequent contributor to and editorial advisory board member for EMS World, he can be reached at rbarishansky@gmail.com.