Pandemic flu: are we ready?

Public bodies have been busy making contingency plans for the pandemic flu, when it comes. It is agreed by experts, that a pandemic will occur, and it is “when” rather than “whether”. Leadership on the development of appropriate plans comes from the World Health Organisation, which continues to provide tracking of unusual influenza outbreaks by monitoring over 100 global centres. National governments have drawn up plans, followed by local councils and NHS Trusts. The UK’s national framework sets out how Government departments and emergency services should try to limit the spread of a pandemic and thereby reduce the potential impact on the economy and number of deaths. Healthcare organisations are being encouraged to make plans based on the Government’s strategic framework so that they are as prepared as they can be. No country can expect to escape the impact of a pandemic entirely, and when it arrives most people are likely to be exposed to an increased risk of catching the virus at some point.1

PANDEMIC FLU

Pandemic flu arises when a new highly infectious and dangerous strain of the virus appears. Every few decades a pandemic occurs, the last one in UK in 1968. The most notorious pandemic in the past occurred after the First World War 1918-1919, it was known as the Spanish Flu and killed 40-50 million people around the globe. The Asian Flu pandemic of 1957 and the Hong Kong Flu of 1968 were less severe in their impact but were still responsible for the deaths of one to four million people.2

It is impossible to predict the precise nature of the impact or indeed the timing of the next pandemic – but one thing that is universally agreed, is that it will happen, and that we are overdue for an outbreak.

A pandemic can occur when three conditions have been met:

• A new influenza virus subtype emerges.
• It infects human beings, causing serious illness.
• It spreads easily and sustainably among humans.

There are major concerns that the H5N1 virus, which causes avian flu, is thought to have the capacity to mutate into the next pandemic influenza virus. Since it emerged in 2003, more than 334 people around the globe have been infected of whom 205 have died. The virus has not yet demonstrated its ability to pass easily from human to human but it has demonstrated its capacity to cross the species barrier, spreading from birds to humans. H5N1 is of special concern because it is particularly virulent, is being spread by migratory birds and, like other viruses, it continues to evolve.

GLOBAL SPREAD

As we learned with SARS, the rate of spread of infectious disease is a modern phenomenon, due to the high mobility of humans flying around the world, spreading germs as we move. The virus would be spread by airborne means, when an infected person sneezes, talks or coughs. It can also spread by contact, through hand/face contact or contact with a contaminated surface.

The worst case scenario envisaged by the UK Government is that more than half the population would be infected within 15 weeks of a pandemic and 2.5% of them would die. This would equate to 750,000 deaths. At the other end of the scale, only one quarter of the population would be affected and only 0.45% or 55,000 deaths would occur. The UN has predicted that globally the death toll could be as high as 150 million people.

The high number of people who may be infected in the case of a mutated H5N1 virus is due to the fact that no one will have any inbuilt immunity. The other problem will be that any possible vaccine production will only be able to be developed after the first global clues of a pandemic occurring. A specific vaccine may take four to six months to develop after the pandemic has emerged.

Currently, immunisation priority groups have been drawn up, which are subject to on-going review and cannot be finalised until a pandemic emerges. Healthcare workers engaged in the direct clinical care of symptomatic flu patients are currently considered the highest priority group for vaccination, once the vaccine has been developed.

ANTIVIRAL TREATMENT

Current supplies of antiviral drugs are being stockpiled, it is claimed, which may be supplied to 25% of the UK population. Antivirals treat symptoms which may shorten the duration of flu and may help to reduce complications. In any pandemic scenario, antiviral treatments may need to be prioritised to ensure the reduction of complications i.e. given to those most likely to be at risk of severe complications; to reduce transmission and spread which should help to lessen the burden of illness on the health and social care system. The UK National Influenza Pandemic Committee chaired by the Chief Medical Officer would provide additional advice, as required during a pandemic.

CONTINGENCY PLANS

The Department of Health (England) is the overall co-ordinator of the UK response together with a wide range of other government departments, all of whom have counterparts in the devolved administrations, and with whom the guidance has been developed. A comprehensive plan was published in November 2007 by the Cabinet Office to give local organisations a strategic framework to assist in the development of local plans.3

Healthcare organisations have been issued with detailed strategic guidance, and are urged to develop their local plans with all stakeholders. An effective response to a developing pandemic will require the collaborative response of many different organisations and the support of the general public. It will be too late to start developing plans once it becomes apparent that a pandemic is emerging.

Under the Civil Contingencies Act, a series of Local Resilience Forums and Strategic Coordination Groups have been set up to respond to a rapidly changing picture across the UK. Their roles are to provide plans and advice for maintaining services and business continuity during a pandemic and to respond to the wider challenges which may result. Information on the evolving guidance is available at: www.ukresilience.info

ACUTE HEALTHCARE ORGANISATIONS

Trusts are advised that when the threat level of a pandemic occurs, the situation will escalate rapidly, possibly in waves or peaks of acuity. Pre-planning for the eventuality, the framework advises, is critical.

Key points for acute Trusts are highlighted with the advisory that planning should be undertaken with consideration of the upper rates of attack rates. Mathematical modelling has been used in the framework document to identify possible impact scenarios.

In summary, Trusts should expect that:

• Up to 50% of the population may show clinical symptoms of influenza over the entire period of a pandemic, and up to 25% may develop complications.

• Up to 2.5% of those who become symptomatic may die.

• Up to 22% of influenza cases can be expected during the “peak week” of a pandemic wave.

• The expected additional demand for healthcare will mean that most influenza patients will require assessment and the majority of their subsequent care and support outside hospital settings. It is anticipated that during an influenza pandemic, hospital capacity will be exceeded, particularly at the peak of the wave.

• Response plans should be flexible enough to deal with a range of possible attack rates.

• Up to 4% of those who are symptomatic may require hospital admission if sufficient capacity is available. • Up to 25% of hospital admissions will be expected to require level three critical care. • The average length of stay for those with complications may be six to ten days.

Specifically, Trusts are advised that pandemic planning will need to be different from other emergency plans they may already have developed, due to the sustained nature of a possible pandemic.

The document highlights that Trusts must be capable of diverting resources in order to respond to the numbers of patients affected, while retaining functionality of its critical systems. It asks Trusts to identify what they believe to be their non-critical/ non-urgent activities as part of the planning phase, so that when the Department of Health communicates that a pandemic has been declared (UK Alert level four), hospitals are able to respond quickly and effectively.

It is suggested that local independent hospitals and independent treatment centres may be able to provide support to NHS trust hospitals during a pandemic by collaborative activity such as to provide facilities for emergency surgery and/or additional capacity for critical care.

In England an additional specific document has also recently been published setting out the ethical framework for policy and planning.4 It covers the principles of specific responses to the pandemic, but also decisions about normal business, including making decisions about clinical and service priorities.

In addition, there is specific guidance on infection prevention for hospitals and primary care Trusts during the pandemic.5 This document provides advice for Trusts on how they may segregate patients into those with influenza and those needing alternative care who should be hospitalised, including separation of patients requiring such services as imaging and diagnostics as well as assessment and admission.

BED DEMAND

It is recognised that bed demand will increase rapidly and substantially during a pandemic. With the cessation of all elective services, capacity can be increased; however, much will depend on how quickly the influenza spreads and the attack rate, locally. Modelling suggests that, at some stages during a pandemic, there will be insufficient bed capacity, particularly level three critical care beds for both adult and especially paediatric patients.

Trusts are reminded that they will need to ensure separate facilities for those who are suffering from influenza requiring level three care, and those who are not infectious, who require it. Further guidance is currently being prepared for Trusts on how to develop additional capacity. It is possible that Trusts may wish to re-commission capacity from redundant facilities; they are encouraged to do this ahead of a declaration of a pandemic, so that a speedy response is possible.

SUPPLIES AND CONSUMABLES

Most procurement is undertaken on a just in time supply basis, which leaves many Trusts vulnerable in a high demand, sustained emergency situation. The framework requests Trusts to identify their key suppliers and ensure that they have robust plans for a sustained surge in demand, such as during a pandemic, with possible interruptions to business activities and logistics deliveries.

STAFFING

The availability of sufficient human resource is critical to maintenance of care to all patients needing assistance during a pandemic. The re-configuration of hospital services will be required during a pandemic and suitable staff provided to support a potentially sustained period of hyperactivity. With re-configuration of services comes potential re-deployment of staff. Trusts are invited, as part of their emergency preparedness, to identify skills and knowledge they will require, and those of the staff they already have. Staff absence during a pandemic should be planned for.

It is suggested that it may rise as high as 20%, taking into account sickness of the individual, carer responsibilities and the additional impact of the closure of schools. Facilities for volunteers and other reserve staff should be planned in advance. A detailed set of human resource guidance is being prepared and will soon be available.

TRAINING

The framework document sets out some of the priorities for pre-pandemic education of staff.

Topics for training are suggested including:

• General awareness of the implications of pandemic influenza.
• Duties of staff including ethical and professional responsibilities.
• Training specific to roles when re-deployed.
• Occupational health of staff during an outbreak.
• Assessment and containment of possible cases.
• Segregation of influenza patients.
• Prevention and control of influenza, including infection prevention and how to reduce transmission risks.
• Staff safety, in particular use of PPE and handling conflict and violence.

It is suggested that Trusts simulate or conduct exercises to test the robustness of their local plans prior to any pandemic. Acute Trusts should, together with their PCTs, develop a programme of activities which will test procedures, systems and physical resources. In addition all staff groups should be tested along with volunteers and other reserve staff. All staff should be aware of the emergency plan, know how to access it, and their roles within it.

The catastrophic effects of a pandemic have certainly been carefully assessed together with their impact on the UK. The framework provides many suggestions for local collaboration and planning. It is apparent that further guidance will be available and that the planning at Government level continues apace.

The guidance will evolve and develop, and Trusts are encouraged to keep their planning process as an ongoing issue with continued referral to the centre for further detail.

It is to be hoped that local organisations have sufficient capacity, with all their current priorities, to spare time for detailed planning for the eventuality. A pandemic has the potential to be a living nightmare for healthcare organisations, and as we are now informed, this is a matter of when, not if. Let us hope that Trusts heed the advice which is given.

REFERENCES

1 Department of Health and Cabinet Office. Pandemic flu: a national framework for responding to an influenza pandemic. November 2007. www.dh.gov.uk/en/ publicationsandstatistics/publications

2 Pandemic flu: your questions answered accessed at www.guardian.co.uk/ society/2007/nov/22/health.birdflu

3 Department of Health. Pandemic flu: a national framework for responding to an influenza pandemic. www.dh.gov.uk/en/ publicationsandstatistics/publications

4 Department of Health. Responding to pandemic influenza – the ethical framework for policy. November 2007. www.dh.gov.uk/en/ publicationsandstatistics

5 Department of Health. Pandemic influenza: Guidance for infection control in hospitals and primary care settings. November 2007.