Symposium on Pandemic Influenza - October 2007
By David L. Lakey, MD
The great influenza pandemic of 1918 swept around the globe, killing 20 million to 50 million people, including more than 500,000 in the United States in its two-year cycle. Many died within the first few days after infection. Others died of complications soon after. Nearly half the dead were young, healthy adults. This pandemic left a public strained to respond not only to monumental illness but also to social and economic disruption.
The 1918 pandemic and, to a lesser extent, the influenza pandemics of 1957 and 1968 provide a planning blueprint. These pandemics show that the unthinkable does happen. They illustrate that a pandemic can be worse than natural disasters because a pandemic is prolonged and progressive, and pandemic influenza planning is not only about health but also about societal issues. We know today that we must account for the possibility of millions of people becoming ill at the same time; for hospital capacity being overwhelmed; for health care professionals becoming infected and unable to work; and for disruption of schools, businesses, and critical services. We also know that if we put off preparations until a novel influenza virus hits the United States it will be too late. Planning must be, and is, under way now.
In some respects, we are at less risk in 2007 from another pandemic than in previous centuries. Advances in medical care continue to move forward rapidly. We have a greater ability to conduct surveillance and quickly confirm an influenza diagnosis. Rapid communication methods allow us to share information within the medical and public health communities and with the public. More effective personal protective equipment is available, and households are smaller.
In other ways, however, people are at greater risk today. More people trade and travel internationally. In 1918, it took 75 days to circle the globe; today, people can make the trip in less than 48 hours. Population density has increased. The public relies more heavily on health professionals, and the population includes more elderly and immunocompromised persons. Today's society is not as accustomed to personal rationing and sacrifice, yet we practice "just-in-time" ordering, which results in limited stocks of food, medicine, and other critical items available at any one time.
Emergency planning is critical. The relevance and success of any plan, however, is more than words on a page. A well-developed plan includes carefully delineated roles and an arsenal of tools that can be used by many at various stages of preparation and response. For pandemic influenza, these tools include antiviral medications, vaccinations, community mitigation strategies, and communications combined with training, practicing the plans, and revising strategies based on drills and new information.
An All-Hazards Approach
Today's approach to emergency preparedness, which brings together the public health, mental health, and medical communities, is based on an all-hazards approach to man-made disasters such as bioterrorism, natural disasters (e.g., as hurricanes), and infectious disease outbreaks. Even with its unique characteristics, an influenza pandemic must be part of an all-hazards approach.
The Texas Department of State Health Services (DSHS) began pandemic influenza planning in 2003 with a single document. Working with partners such as the Texas Medical Association, DSHS is updating the original plan and developing a series of documents that detail specific preparedness and response measures. The DSHS Pandemic Influenza Response Plan is Appendix 7 to Annex H Health and Medical Services, a part of the Texas Homeland Security Strategic Plan. Appendix 7 identifies roles and responsibilities of state partners in response and recovery. The plan's purpose is to limit the spread of the virus; minimize serious illness, hospitalizations, and death; sustain critical infrastructure; and minimize social disruption caused by pandemic influenza. This plan is focused on preparing for human pandemic influenza. The state's Foreign and Emerging Animal Disease plan addresses preparing for a coordinated response to zoonotic disease outbreaks, including avian influenza.
Among the assumptions of Appendix 7 are that seasonal influenza vaccination may offer some protection against a novel pandemic influenza strain but that it is highly unlikely that the most effective tool for mitigating a pandemic - a well-matched pandemic strain vaccine - will be available when a pandemic begins. Another assumption is that children will play a major role in transmission of infection. Their illness rates are likely to be higher, they shed more virus over a longer period of time, and they control their secretions less effectively.
Pandemic influenza surveillance will provide information critical to implementing control measures such as restricting travel, closing schools, canceling public gatherings, and initiating antiviral vaccine use in target groups. Systematic application of control measures can significantly reduce transmission rates and the intensity and velocity of pandemic influenza.
With guidance from the Governor's Division of Emergency Management, DSHS coordinates state health and medical services and serves as the primary state agency identified in the State of Texas Emergency Management Plan for coordinating pandemic influenza preparedness, response, and recovery. DSHS will:
- Identify target populations to receive available antiviral medications and vaccines;
- Coordinate state efforts to distribute resources from the federal Strategic National Stockpile (SNS);
- Develop and maintain a statewide pandemic influenza surveillance system;
- Sustain the state's laboratory capability to rapidly identify and subtype influenza virus; and
- Coordinate the provision of disaster behavioral health services to first responders and those affected by a pandemic.
Another DSHS document, the Pandemic Influenza Plan Operational Guidelines, describes in detail the responsibilities of DSHS on a state level, the eight DSHS Health Services Regional offices, and local health departments. These guidelines are organized around three areas: preparedness and communication, surveillance and detection, and response and containment. Within each area, the guidelines are sequentially developed according to the World Health Organization's pandemic influenza phases and corresponding federal stages.
Other DSHS planning documents under development include Antiviral and Vaccine Allocation, Distribution, and Storage guidelines that provide information about target groups, distribution points, allocation methods, storage details, and safety issues. The 80th Texas Legislature appropriated $10 million in general revenue funds this year to purchase additional antivirals for the state supply. This allocation will secure about 675,000 courses. In addition, DSHS has already purchased nearly 150,000 courses; and the SNS Texas allocation is about 3.3 million courses, providing Texas with just more than 4 million courses.
Antivirals are the only medicine for use against influenza that we have now. But antivirals are not a silver bullet for pandemic influenza planning. They are, rather, one part of a comprehensive strategy.
In emergencies, response begins at a local level. In most cases, when a community needs assistance, other communities, organizations, state partners, and the federal government can provide assistance as needed. But an influenza pandemic will be vastly different in both duration and magnitude. Response will cover months, not weeks or days. Waves of illness may wash across community after community, state after state, around the country and the world. Individuals, families, and communities must prepare to be on their own for extended periods. Everyone will be affected in some way.
Social distancing interventions can be undertaken by almost all communities. These strategies include isolation of the ill; voluntary home quarantine of those exposed to the ill or with probable influenza; and such measures as closing schools and child care programs, canceling public events, staggering work hours, and enabling telecommuting. Businesses can develop leave policies that support adherence to these nonpharmaceutical interventions. Such interventions, when used early, can delay outbreak peak; decompress the peak burden on physicians, hospitals, and the community infrastructure; and diminish overall cases and health impacts.
Planning Saves Lives
A look at the great influenza pandemic of 1918 offers a blueprint for planning. Look at two U.S. cities - St. Louis and Philadelphia. On Oct. 7, 1918, the mayor of St. Louis ordered all theaters, picture shows, schools, pool and billiard halls, Sunday schools, cabarets, lodges, societies, public funerals, open air meetings, dance halls, and conventions closed or canceled until further notice. In contrast, Philadelphia continued life as usual. The 1918 flu/pneumonia death rate per 1,000 by city shows the Philadelphia death rate at 7.4 and that of St. Louis, at 2.2, a decrease of 70 percent ("Causes of Geographical Variation in the Influenza Epidemic of 1918 in the Cities of the United States," Bulletin of the National Research Council , July 1923, page 29).
Community mitigation practices are critical. DSHS is developing Community Mitigation Guidelines that discuss legal powers of the governor, health commissioner, medical authorities, and others related to invoking social distancing activities such as school closure, cancellation of public gatherings, isolation, and quarantine.
Taken together, at all levels, planning is paramount. Pandemic influenza could last longer and cost more lives than any other threat. Controlling and monitoring pandemic influenza will involve partnerships with many private, local, state, and federal agencies, not just those traditionally associated with public health activities. These partnerships are critical to our success. Integrated planning and exercises are essential. Communication among partners such as TMA is invaluable. Millions of lives may depend on it.
Dr. Lakey is commissioner of the Texas Department of State Health Services.
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