This report originally appeared in the August 2010 issue of DOTmed Business News

While there were more than a few pandemics in the last century, the flu hitting in 1918 and 1919, which claimed more than 50 million people, is definitely one that sticks in the minds of the professionals trying to gain government support for action plans and training. Recent years may have offered a brief, and possibly false, sense of security.

With the emergence of H1N1 and the concerns over the avian flu mutating and the ever-present concern that another, even more sinister pathogen is waiting for the right opportunity, infection control and emergency plans for dealing with pandemics are becoming key concerns.

The outbreaks of H1N1 and the potential problems of avian flu in 2009 and early 2010 were deemed "wake-up calls" and "drills," by pandemic preparedness experts because the outbreaks weren't nearly as potent as everyone had thought they would be. But before the potency, or lack of potency was determined, hospitals throughout the country and all over the world prepared to battle what some feared would be this generation's Spanish influenza pandemic.

In some cases, hospitals were prepared. In others, they realized their plan wouldn't have been effective had the virus been deadlier. But in all cases, hospitals gained knowledge from the experience and used it to critique and reassess their emergency preparedness plans.

"A severe pandemic would have had the entire U.S. affected simultaneously," says Ann Knebel, deputy director for preparedness planning for the Office of the Assistant Secretary for Preparedness and Response. "But that wasn't how H1N1 played out...It never hit the entire U.S. simultaneously. Plans are great, but they always have to be adjusted when dealing with events because a scenario never plays out like you thought it would. [In this case] it worked to our advantage...Because of the planning for a severe pandemic we were able to respond to what was going on without outside assistance," she says.

Ready for battle

Hospitals tend to group all disasters - pandemics, earthquakes, terrorist attacks - into one preparedness plan, tweaking parts of it to address specific challenges presented by each type of disaster. Hospitals are not required to have preparedness plans, but it is a factor in receiving accreditation, explains Kelly Fugate of the Joint Commission's Division of Standards and Survey Methods. The Joint Commission is a hospital accreditation organization.

Hospitals and health organizations across North America say communication and preparation are the most important factors in battling a pandemic.

"Through planning ahead of time, you're able to look at what disasters you may or may not face," says Matthew Fenwick, associate director for the American Hospital Association's media relations department. "Plan accordingly with resources you need, extra supplies and relationships with first-response [teams]."

Wisconsin's Department of Health's preparedness program, which has a 99 percent compliance rate, has three main goals to prepare for whatever "the bad guys or nature throw," says Dennis Tomczyk, director of hospital preparedness for the state's division of public health. The department's goals are similar for hospitals and health departments worldwide.

Health care facilities should be able to deal with a surge, or influx, of patients, Tomczyk says. But not only should facilities be able to handle a surge, it should be for a sustained period of time.

"When you're dealing with more severe trauma, especially infectious disease, you're talking, days, weeks, and that's a difficulty," says Tomczyk.

In order for these goals to be met, the third goal must be fulfilled, which is being able to collaborate with other health care facilities and emergency responders.

"Everybody has to have their plans integrated," he says.

Dr. Kevin Chason, director of emergency management for Mount Sinai Medical Center, dealt with the recent H1N1 pandemic firsthand. He agrees that in order for a preparedness plan to be effective, partnerships and communications are key.

"I emphasize working very closely with partners at other hospitals and the city and the state health department and other agencies that will be part of the response," says Chason. "[It's important to communicate] the same message so the public gets a good idea of what their responsibilities are and what our responsibilities are and how we can help one another to get through something like this in a safe, effective way."

The World Health Organization's (WHO) initiative for infection prevention control in health care also recognizes the importance of collaborating with other networks. During the recent pandemic, the WHO made an effort to work hand-in-hand with both internal and external organizations to prepare for the outbreak. But even the prestigious organization has some areas of concern to address.

"I think that we still need to improve a lot in terms of not only partners within WHO, but also, perhaps more importantly, external partners," says Dr. Carmen Pessoa-Silva, medical officer for WHO and project leader for the initiative for infection prevention control in health care. "We do need to do more work to strengthen readiness for partners to be working together during an emergency situation."

Experts point out, in order to determine whether a hospital's plan will work against a pandemic, it's crucial to run through the procedure beforehand. While events won't be exactly like the drill, following the drill will let health care workers and emergency response teams get comfortable with a similar situation. This was a lesson learned for some hospitals in Canada.




Amid the second wave of H1N1 last December, Canada's CSA Standards held a roundtable discussion with health care professionals to discuss what went well and what needed improvement in the country's handling of the pandemic.

"The major areas [that need improvement are] around the actual pandemic plans," says Dr. Allan Holmes, president of Global Medical Services and roundtable moderator. "We didn't really have a coordinated planning system between the federal government and the local health groups...It was difficult to try to respond almost on the spot."

Holmes notes that failing to have a proper plan in place could have been disastrous if hospitals had to deal with a surge of patients.

"If we had a lot more people ill with H1N1 it probably would have overtaxed the system," he says. "...Canadian hospitals are at 95 percent to 100 percent capacity in general. There's not a lot of surge capacity. When something like [a pandemic] causes a high surge, plans in place really need to address that."

The roundtable discussion and its corresponding white paper are efforts to address shortcomings in pandemic preparation.

"We want to make sure the message is there for the next time," says Holmes. "For a more severe pandemic, we need to do more to make sure we're better prepared."

In short supply

Most hospitals order supplies based on a "just-in-time" philosophy, preparing them for the week ahead, not what may be needed in the face of a pandemic, explains Barbara Russell, who chairs the Emergency Preparedness Committee for the Association for Professionals in Infection Control and Epidemiology (APIC).

"Just-in-time philosophy is not good for preparation," says Wisconsin's Tomczyk. "It's good for finances, but it doesn't help you in a disaster if you don't have [supplies] right there."

Hospitals, when organizing a pandemic preparedness plan, especially for influenza, should consider supplies such as personal protective equipment (PPEs) - gloves and surgical masks - vaccines, antiviral medications like Tamiflu and most importantly, hospital staff.

Mount Sinai Medical Center not only worked to maintain supply recommendations from the New York Department of Health and the Centers of Disease Control and Prevention (CDC), it also installed alcohol-based soaps throughout the hospital. This was just one of many steps the hospital - based in congested New York City - took to protect patients and employees.

The H1N1 outbreak forced health care facilities to turn to surgical facemasks and at the recommendation (and during the second wave, a requirement) of the CDC, N95 respirators for barrier protection. This is where Mount Sinai experienced its shortcoming. While hospital staff was fit-tested for one type of respirator for the stockpile, manufacturers fell short in supplying enough of them during the second wave of the pandemic.

"If one vendor can't keep up and you move on to another mask, you then need to fit-test [for that mask]," says Chason. "In the middle of a crisis when you run out of masks, you have to figure out how to fit-test another brand of masks."

As a direct response to this problem, the hospital's policy is to now stockpile more than one brand of masks that have been fit-tested for hospital staff.

According to a joint survey conducted by APIC, Materials Management in Healthcare (MMHC) and the Association for Healthcare Resource and Materials Management, 60 percent of respondents said they experienced a shortage of the respirators prior to December 2009, and one-third indicated they had to undergo new fit-testing.

Masks and respirators were all the rage during the outbreaks. In fact, a 2009 study published in Annals of Internal Medicine showed that H1N1 patients who wore face masks were less likely to pass the virus on to others. Masks were a common supply in both hospital and national stockpiles during the recent pandemic, but in some cases, suppliers couldn't produce fast enough. According to the MMHC survey, 38 percent reported a shortage in surgical masks prior to December 2009.

Mike Bowen, executive vice president of Prestige Ameritech, which manufactures surgical masks, had an influx of orders from hospitals that were stranded by their overseas suppliers.




"Everyone started panicking," he says. "...Hospitals were pleading with us for more products. They couldn't get them from their normal suppliers. We were turning away customers...We turned away millions in orders."

When the surgical mask industry moved overseas, hospitals didn't consider the effects relying on those suppliers would have if a pandemic hit, says Bowen.

"The first thing you need to ask yourself is, in a global emergency do you want the mask supply in the U.S., controlled by U.S. health officers, or in China?" Bowen says. "Are they going to send masks to us when people [over there] are dying?"

In an effort to help hospital clients, Prestige Ameritech opened the Global Pandemic Preparedness and Response Center last March - a stockpile of masks made available to customers during shortages at no extra cost. Development began about five years ago when American mask manufacturers moved south to Mexico or overseas.

"We're going to build this company on the pandemic story and the national story," says Bowen.

Protection: Cost of an arm

The development of the H1N1 vaccine during the midst of the pandemic was hotly debated, as tends to be the case for new vaccines: was it safe? The CDC reported a similar safety profile between H1N1 and the seasonal flu vaccine. But even with some skeptics skipping out on the vaccine, there was still a shortage. This fall's seasonal vaccine will include the 2009 H1N1 strain, according to Dr. Michael Shaw of the CDC.

The vaccine uptake wasn't as high as some health care officials had hoped, says ASPR's Knebel.

"We're trying to understand why health care providers did not accept the vaccine in as large numbers as we would have thought," she says. "If it had been a more severe pandemic...[not getting the vaccine] really could have hurt us in terms of being able to staff the health care system."

"Vaccination is still highly underutilized for whatever reason," says the Joint Commission's Fugate.

According to a CDC survey, 37 percent of health care workers polled said they received the H1N1 vaccine versus 62 percent for the seasonal flu vaccine.

Mount Sinai's Chason says vaccination was one of the biggest countermeasures against the H1N1 pandemic. But that important measure was difficult to carry out in his facility, which had a hard time getting enough of the vaccine and putting together a system that would vaccinate staff quickly.

While New York state requires vaccination for its health care workers, the law was temporarily suspended due to supply issues, says Chason.

"Ultimately, there were enough vaccines available, but early on, distribution allotments were not sufficient to vaccinate every health care worker and patient," he says. "We had to provide vaccines to our highest-risk patients and staff and then to everyone else."

According to the MMHC survey, almost half of respondents reported that the inadequate supply of vaccines impeded immunization for front-line health care workers early last fall.

In order to protect its staff, University Health Network (UHN) - a network of Canadian hospitals - made its hospital staff top priority when administering the vaccine. The network reported a 95 percent uptake in the vaccine, says Gillian Howard, vice president of public affairs.

The high uptake, says Howard, "meant we had staff available to work. It was a mild pandemic, but when planning, plan for the worst-case scenario."

A study published in Health Service Research in June found that vaccination rates increased as mass media coverage of flu-related topics increased. According to data from the 1999 to 2001 flu seasons, which included a vaccine supply shortage or delay, annual vaccination rates increased by 8 percent.

The researchers found that when mass media outlets, including the four major television networks - ABC, CBS, NBC and Fox News - and other key media such as The Associated Press and USA Today, mentioned the influenza vaccine there was a "spike" in vaccination activity, according to the report.

But the mass media can also cause undo hype, according to Fugate.

"We learned that the public panics and the media don't necessarily always help," she says, regarding lessons learned from H1N1. "Last season was not as bad as all of the hype leading up to the season led us to believe."

Lessons learned

Perhaps UHN's success in standing strong against H1N1 was its prior experience with infectious disease outbreaks. Nearly a decade ago, Toronto - where UHN's hospitals are located - was hit with an outbreak of severe acute respiratory syndrome (SARS).

"Because [Toronto] had SARS, there was a heightened awareness to plan early [for a pandemic]," says Howard.

While the city didn't know the H1N1 pandemic was coming, it knew the importance of being prepared.

"We knew that given the history of flu pandemic, if it wasn't this year it's going to be another year," Howard says. "We know a pandemic will come, it's just a question of time and how to prepare."

Using knowledge from the SARS epidemic, Howard's team had a very aggressive screening program for people coming into the hospitals with unknown respiratory illnesses.

Vaccinations were administered as the first line of defense, and due to the SARS stockpile, the hospitals had more than enough N95 respirators to get them through the first wave, says Howard.

"Surgical masks would have been just fine," she says. "...They probably weren't necessary for the flu, but given the experience of SARS, that's not something we were going to be able to convince people of."

But even a city as prepared as Toronto wouldn't have been able to handle a surge of patients, had the pandemic been more severe.

"If it had been a severe pandemic, it is certainly true that all hospitals would have run out of ICU capacity, ventilation equipment and trained users," says Howard. "I'm not sure society prepared people for the kinds of decisions that might need to be [made]."

Still, even basic measures may prove to make the difference in fighting off future pandemics. Many hospitals are already taking extra steps to minimize the potential. In fact, according to the MMHC study, 84 percent of respondents provided facial tissues, no-touch receptacles for tissue disposal and hand sanitizer in waiting areas and exam rooms.

Back to basics

As hospitals and their emergency preparedness teams look back on the 2009-2010 pandemic of H1N1, they note what improvements need to be made, what they did well and where their plans fell short. But ultimately, keeping the virus in control came down to the fundamentals: hand-washing and basic infection control.

Gregg Pane, ASPR's director of hospital preparedness, points out that the health care facilities that fared a lot better during the 1918-1919 pandemic adhered to all of the basic infection control rules.

"We learned from 1918, that just washing hands, covering coughs, social distancing - those communities did better," he says. "Basics are always the underlying foundation to everything else."

In addition to the basic rules of hygiene and infection prevention, experts reflecting back on the H1N1 pandemic point out that it's important to talk and communicate and recognize that a pandemic is always looming.

The future "is something we need to encourage people to talk about," says Howard. "People don't really want to talk about it...For us, planning was the key. It's difficult to plan when really nothing exciting is happening...It's hard to keep people planning when the threat doesn't seem imminent."

With every infectious disease outbreak, pandemic or not, the public and health care professionals learn what worked and what didn't. But even with careful, meticulous planning, the unexpected inevitably happens.

With regard to the 1918-1919 pandemic, Knebel asks, "Are you ever ready for something that's that overwhelming?"