Pandemic Preparations
President Bush and Congress have approved
plans to safeguard
against Avian Influenza. While the public may wonder why it is a
big deal, some in the medical field say the plans are insufficient.
against Avian Influenza. While the public may wonder why it is a
big deal, some in the medical field say the plans are insufficient.
A patient presents with fever, cough, sore
throat, and muscle aches—similar to typical flu. But if
the symptoms grow worse rapidly, perhaps including pneumonia,
acute respiratory distress, and organ failure, the disease
could be H5N1, also known as Avian Influenza A.
As of December 2005,
fewer than 100 people are known to have died worldwide from
Avian Flu, and those people acquired the disease directly from
birds, probably from contact with the birds’ feces or
blood. The growing concern is that this virus or another will
undergo an antigenic shift (with new proteins on the surface of
the virus) enabling the virus to spread from human to human,
and resulting in a pandemic. H5N1, in its current form, has had
a 50 percent mortality rate.
$3.78 billion in funding
In December, Congress passed a defense
spending bill (HR 2863),
containing $3.78 billion to prepare for and respond to an
influenza pandemic. The funds are only about one half of the
$7.1 billion that President Bush requested. Conservatives in
Congress were reluctant to spend a larger amount in the coming
fiscal year without making budget cuts in other areas. If an
actual pandemic strikes, more emergency funding is likely to be
approved.
The largest portion of the
funds approved ($3.3 billion of the $3.78 billion) will go to
the Department of Health and Human Services. A major portion of those funds is likely to be
spent on cell-culture technology to seek to reduce the time
needed to identify new viruses and develop vaccines. Currently,
most vaccines are produced by injection of individual eggs, a
comparatively slow process. Technology allowing the vaccine to
be produced in vats would expedite the production. Additional
money is likely to be allocated, at the department's
discretion, to purchase vaccines and stockpile antiviral
medications such as Tamiflu and Zanamivir.
Another portion of the
defense spending bill, entitled the “Public Readiness and Emergency Preparedness
Act,” grants immunity
from state and federal lawsuits in connection with the
manufacture and use of vaccines or other “covered
countermeasures” designated by the Secretary of Health
and Human Services. Under the act, liability could be imposed
only if there was clear and convincing evidence of
“willful misconduct”—a very difficult burden
of proof for plaintiffs.
200,000 deaths in the U.S. possible
The U.S. Centers for Disease Control and
Prevention (CDC) estimates that
a “medium-level” pandemic could cause 89,000 to
207,000 deaths in the United States and between 314,000 and
734,000 hospitalizations. In addition, there could be 18 to 42
million outpatient visits, with 15 to 35 percent of the
population affected by influenza. The economic impact,
according to the CDC, “could range between $71.3 billion
and $166.5 billion.” And that is just for the
“medium-level” pandemic. Information from the CDC
about pandemics is available on line at www.cdc.gov/flu/pandemic.
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International efforts
Some critics of the Bush proposal say that
more money should be allocated to international efforts,
arguing that prevention of an outbreak in other countries is
the best defense against a pandemic in the U.S. More money
could be spent on surveillance and detection of flu abroad as
well as prompt efforts to contain an outbreak by, for example
destroying flocks of infected birds and vaccinating and
treating people in affected areas. The World Health
Organization (WHO) is
considering establishing an international stockpile of
antiviral drugs that could be deployed at the beginning of a
pandemic.
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regarding influenza, see www.who.int/csr/disease/avian_influenza/en/
Lack of surge capacity in hospitals
Another criticism of the Bush plan comes
from the American College of Emergency Physicians (ACEP). Although the emergency physicians commended
the administration for issuing a pandemic influenza plan, the
physicians also said that inadequate attention was given to
developing the nation’s hospitals’ surge capacity
and ability to isolate patients. Over the last decade, the
nation has lost 103,000 staffed hospital beds and 7,800
intensive care unit beds.
Dr. Rick Blum, the
president of ACEP, cites an example of capacity problems in
Toronto, Canada during the 2003 SARS outbreak. “[T]he
second SARS victim, who was thought to have pneumonia, was held
in one of the city’s emergency departments for an
extended period of time until an inpatient bed became
available. As a result, 78 people were infected, five of whom
died—all as a result of one admitted patient spending the
night in the emergency department instead of an inpatient
unit.” ACEP supports more funding for emergency
departments.
Contingency planning for business
The Bush administration and a variety of
organizations urge businesses, including medical practices, and
governmental units to develop plans to deal with a pandemic.
Elements of the plans could include:
a Having
priority lists of core functions that should be performed (and
a list of functions that would not be performed if there were
insufficient staff or supplies)
a Establishing
methods of infection control in the workplace, such as sick
workers staying home, education of workers, and lots of
hand-washing
a Encouraging
work from home, if possible
a Avoiding
travel that is not essential
Even with plans to
continue work during a pandemic, the economy could be crippled
if the level of fear rises high and people are unwilling to go
to work or deliver supplies for fear of being infected. In the
event of a pandemic, medical practices might be more affected
than other businesses by staff shortages because the number of
health-care workers can be expected to drop since they will be
at high risk of illness through exposure to the virus. They may
also miss work in order to care for sick family members.
In addition, the CDC
notes, “A pandemic will last much longer than most public
health emergencies and may include waves of influenza activity
separated by months. (In 20th century pandemics, a second wave
of influenza activity occurred 3 to 12 months after the first
wave).”
Isolation and quarantine
For individuals and families, measures
similar to those for businesses would apply. Public health
officials also might impose isolation and quarantines and limit
public gatherings. Families are encouraged to stock sufficient
supplies to be able to stay home for several days, if
necessary. Families, however, are asked not to stockpile
antivirals such as Tamiflu since that could interfere with the
ability of health officials to deliver the medicines to where
they are needed most and also could result in unnecessary
treatment.
The federal
government’s plan likely will include prioritization of
who receives antivirals. Dr. Rajeev Venkayya, the special
assistant to the president for biological defense policy, said
priority would be given to “those individuals at greatest
risk for exposure, and those people on the front lines,”
including workers in health care, border patrol,
transportation, and agriculture.
As of this writing, the
H5N1 Avian Flu has not mutated to a form that results in
human-to-human transmission. Whether or not this virus will
result in a pandemic is not known, but most experts agree that
it is only a matter of time before another pandemic strikes.
Actions by the administration and Congress are steps in the
right direction, but plans should continue to be improved with
particular attention to rapid production and distribution of
vaccines, increased international efforts to identify and
contain outbreaks, and more planning for surge capacity for
health-care facilities. g
Jeff
Atkinson teaches courses
in health-care law and policy at DePaul University College of
Law in Chicago, where he graduated summa cum laude. He writes
on legal, medical, and ethical issues.
