Preparing for the worst: Health care workers at core of CDC pandemic flu plan
Preparing for the worst: Health care workers at core of CDC pandemic flu plan
Guidelines urge hospitals to boost vaccination rates
Saying it’s a certainty that a devastating new strain of influenza will eventually wreak havoc worldwide, the Centers for Disease Control and Prevention in Atlanta has developed a draft guideline for hospitals and other health care facilities to follow in preparing for an influenza pandemic.
Making sure that health care workers are protected and capable of caring for an influx of patients lies at the heart of the plan.
"One of the biggest issues in a pandemic is going to be maintaining infrastructure," says Martin Myers, MD, acting director of the CDC’s National Vaccine Program Office. "The infrastructure that’s going to be really critical is the health care work force."
According to the CDC, hospital employee health professionals should become a part of communitywide planning to address difficult questions that arise during a pandemic: Who should be the first to receive vaccines that are in short supply? Should some unvaccinated health care workers take antiviral medication prophylactically? How should health care workers with influenza-like symptoms be restricted? (For a summary of the CDC’s draft recommendations, see story on p. 76.)
Meanwhile, improving compliance with long-standing employee health practices such as influenza vaccination and standard precautions would actually help hospitals prepare for a pandemic, Myers says. (For information on the latest Advisory Committee on Immunization Practices guidelines, see related story on p. 77.)
"If we had a high proportion of our health care work force and people over the age of 50 getting their vaccine as recommended, we would already have a piece of the infrastructure in place," says Myers. "Health care workers are notorious for not getting their routine influenza vaccination."
Increased demand for routine vaccination would ensure that vaccine manufacturers have the products on hand to make the egg-based vaccine, he says. The vaccine delivery system also would be larger and more efficient.
Hong Kong scare was a warning
The potential for a swift spread of pandemic influenza became menacingly apparent in 1997, when 18 people in Hong Kong became infected with an avian flu strain that had never before been seen in humans. Most were exposed through contact with poultry, but two health care workers became infected through close contact with patients, demonstrating that the influenza strain could be transmitted by person-to-person contact.1
The outbreak was contained when millions of chickens were slaughtered before the start of the annual flu season, when a common strain could have mixed with the new avian strain and led to more rapid spread.
"[A pandemic is] a novel virus that few people, if any, have pre-existing immunity against," says Carolyn Buxton Bridges, MD, a medical epidemiologist in the influenza branch of the CDC. "The other requirement [for a pandemic] is that it’s easily transmissible. [The Hong Kong outbreak] did not fulfill the second criterion." Yet the avian H5N1 influenza A strain may still exist in wild birds and still could pose a risk, she says.
Unlike the seasonal waves of common influenza strains, an influenza pandemic strikes otherwise healthy people as well as the usual risk groups of the elderly, the very young, and those with compromised immune systems. The 1918 Spanish influenza pandemic is legendary for its virulence: More than 20 million people died worldwide, including 500,000 in the United States. Some victims were healthy in the morning and dead by nightfall.
Less fearsome pandemics occurred in 1957 and 1968. "There’s no simple answer to the question of how serious the next pandemic might be," CDC influenza experts stated in the draft guideline. "It depends on how virulent and transmissible the virus is. Since our world today is vastly more populated than it was during previous pandemics, and people travel the globe with ease, the spread of a next pandemic could be more rapid than that of previous pandemics."
That is why a quick response to a possible pandemic is so important, says Bridges. In fact, how well hospitals handle the seasonal epidemics may indicate their level of readiness.
Hospitals need to improve vaccination
Unfortunately, many hospitals have low levels of vaccination of health care workers and inadequate surveillance or personnel policies to prevent nosocomial spread, Bridges says. CDC guidelines state that health care workers should receive influenza vaccinations annually. But in the 1997 National Health Interview Survey, only 34% of health care workers reported that they received influenza vaccine.2
At Dartmouth Hitchcock Medical Center in Lebanon, NH, Kathleen Golden McAndrew, MSN, ARNP, COHN-S, CCM, department director and nurse practitioner in the section of occupational medicine, is trying to boost vaccination rates by offering the vaccine in each clinic area and at all shift times. "One of the problems we hear is that folks don’t have time to come down [to employee health]. So we’re going to bring it to them," she says.
Flu may seem like more of a nuisance than a serious health threat, but it can be deadly to vulnerable populations. In an average influenza season, the virus may be linked to 20,000 to 30,000 deaths in the United States alone.
"A pandemic may be very devastating and overwhelm medical resources. But even during regular influenza epidemics in large cities, [hospitals] may see medical services overwhelmed," says Bridges. "That raises questions about how well prepared we are for a pandemic, if even during the epidemic hospitals have to close their doors to new admissions or divert patients during the flu season because they get so overwhelmed with patients."
The CDC’s draft guidelines call for isolating patients with influenza and comorbid infections as much as possible and minimal transport of infected patients. Future CDC guidelines will recommend priority groups for vaccination, but the CDC has already noted that hospitals should identify their most essential staff who should receive the first vaccinations.
Vaccinated staff then would be dedicated to treating patients with influenza. During a pandemic, when hospitals are overwhelmed, health care workers with influenza-like symptoms who are well enough to work may be assigned to care for patients with known influenza, the draft guidelines state.
Improve hand hygiene, gloving
Yet, at their core, the pandemic guidelines encourage health care facilities simply to follow practices already in place: hand washing, gloving, and wearing masks, when appropriate.
"This is basic infection control and prevention," notes Geoff Kelafant, MD, MSPH, FACOEM, medical director of the Occupational Health Department at Sarah Bush Lincoln Health Center in Mattoon, IL.
Kelafant notes that the CDC pandemic guidelines also may prompt hospitals to become more vigilant in their surveillance. For example, many hospitals don’t follow a procedure to clear health care workers who return to work after being out for several days with influenza-like symptoms.
"At my institution, if you’re out more than three days, you have to have a note from your doctor to come back to work," says Kelafant. However, "we’re kind of lax on that," he adds.
During a pandemic, officials will assume any influenza-like illness is the new strain. But surveillance is critical in detecting the first stages of a pandemic and containing the seasonal flu epidemics, says Bridges. Rapid tests are available to identify the common influenza strains within 15 minutes.
"Generally, people who are adults who are infected with influenza may be infectious for around five days," says Bridges. "People are most infectious for the first three days of their illness. Occupational health people should have some kind of guideline to guide managers about how to handle health care workers who are ill."
Bridges notes that nosocomial influenza outbreaks have been reported in neonatal ICUs, bone marrow transplant units, intensive care units, and oncology units. "Among high-risk groups, those outbreaks are devastating," she says.
Antiviral medication also may play a part in a hospital’s response to a pandemic, but the CDC has not yet released recommendations on the use of antivirals. An expert panel is considering various issues, including cost-effectiveness and side effects.
Two agents, amantadine and rimantadine, have been shown to provide prophylactic protection against influenza in 70% to 90% of cases. However, Bridges notes that in a small percentage of people, the antivirals can cause central nervous system side effects, including confusion, decreased concentration, and insomnia. Those effects have been more frequently reported for amantadine (13%) than rimantadine (6%).
"These are licensed drugs that will play an important part in a pandemic, but we don’t know [in what way] yet," says Myers.
McAndrew notes that the antiviral medication may become important if not enough vaccine is available to protect health care workers.
While employee health professionals can create an action plan, the actual response will vary greatly depending on the nature of the pandemic itself.
"There needs to be an outline to what you want to do. But getting specific depends on how hard it hits, and variables such as how much vaccine we have for the pandemic," she says.
(Editor’s note: The three draft pandemic flu guidelines mentioned in this story have been posted on the American Health Consultants Web site at www. ahcpub.com/online.html. Click on "Hot Topics" and then "Breaking News." Employee health professionals can comment to the CDC on these proposed guidelines via e-mail by going to www.cdc.gov/od/nvpo/. Click on "Enter NVPO" and then on "Contact Us." The CDC is sponsoring an educational satellite broadcast on July 13 on preparing for a pandemic. For more information, see the CDC’s pandemic influenza Web site at www.cdc.gov/od/nvpo/pandemic.)
References
1. Bridges CB, Katz JM, Wing HS, et al. Risk of influenza A (H5N1) infection among health care workers exposed to patients with influenza A (H5N1), Hong Kong. J Infect Dis 2000; 181:344-388.
2. Walker FJ, Singleton JA, Lu PJ, et al. Influenza vaccination of health care workers in the United States, 1989-1997. Infect Control Hosp Epidemiol 2000; 21:113.
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