Thinking about an influenza pandemic should make any respiratory care practitioner a bit edgy. The possible surge of large numbers of very sick, hospitalized patients—many of whom will require extensive respiratory supportive care—is daunting. Widespread illness will put a serious strain on our health care resources, both staff and facilities. Fortunately, many hospitals and health care facilities along with their communities are working hard to plan and prepare for a pandemic influenza and the resulting surge in patients, from the worried well to the extremely sick.
What makes a pandemic flu so virulent? Normally, influenza is generally an acute, upper respiratory infection that is self-limiting. With a short incubation period, it is communicable before the onset of symptoms and spreads easily from person to person through coughing and sneezing.1 Antibodies interact with the antigens on the virus surface and incapacitate the pathogen. These antigens contain proteins called hemagglutinin (H) and neuraminidase (N). An “antigenic drift,” as seen in the minor seasonal influenza virus changes from year to year, allows the host body to create an “immunological memory” that assists in combating these influenzas, even if they are not exactly the same strain seen previously. The dramatically different antigenic shift represents a sudden change in the antigenic proteins H and N to a virus strain not previously experienced before. The body does not have an immunologic memory for these new viruses, which leaves the body highly vulnerable to infection.1,2
Typically, antigenic shifts are caused by genetic reassortment, wherein human influenza viruses intermix with animal influenza viruses.1 Many wild and domestic animals are susceptible to animal influenza viruses, such as the avian influenza. Generally, animal influenza viruses do not transmit easily to humans. The potential for a pandemic occurs when a host is coinfected with both the animal and human influenza virus, causing genetic reassortment within the viruses. As the quantity of coinfections increases, the likelihood of more contagious reassortment increases, and human-to-human spread is more easily accomplished.1,2
Currently, the H5N1 virus appears to be the most likely strain to generate an influenza pandemic. The H5N1 virus, an avian influenza affecting mainly birds, has mutated, infecting some humans and causing some deaths. Virtually all of these reported cases have developed from direct human to infected bird contact. While the H5N1 virus has shown some capacity of making the jump from birds to humans, the virus does not, as of yet, show signs of increased reassortment.3 With each new human case reported, scientists are tracking the changes in the strain for any mutations that would make human-to-human transfer more possible.
Symptoms and Course of Flu
Symptoms of influenza can vary, depending on the severity and the individual. Typically, symptoms include fever, headache, chills and shaking, aching muscles and joints, loss of appetite, weakness, sore throat, runny nose, and nausea or vomiting.4 Complications from influenza can include bronchitis, sinus infections, and pneumonia. Anyone with a depressed immune system could experience these complications, plus complications from other existing health issues, such as heart problems, lung disease, diabetes, chronic kidney disease, severe anemia, or immune-system problems. The flu can be contagious for a week or longer, starting the day before the symptoms start and up to 5 days after symptoms subside. The virus spreads through direct contact or through the air from coughing or sneezing.2 The World Health Organization and Centers for Disease Control and Prevention recommend the use of standard, contact, and airborne protection including respirators of N95 standard or higher.5
Why is the pandemic influenza virus so debilitating? When a virus invades the body, chemokines, a class of cytokine or messenger proteins, signal the immune system to fight the invader. When the invader has been destroyed, the immune system stands down, and the body resumes normal functioning. In a pandemic influenza, the immune system is overexcited, producing much greater levels of cytokines. This hypercytokinemia, also called a “cytokine storm,” is an inappropriate and exaggerated immune response.2,6 When the cytokine storm occurs in the lungs, as in pandemic influenza patients, the lung tissue becomes choked with debris from the unrelenting inflammatory response, causing severe damage to the lung tissue.3 The cytokine storm must be subdued and treated or permanent pulmonary damage will occur with death as a possibility.6 Autopsies of human victims of the H5N1 virus in Southeast Asia have revealed that their lung tissue suffered from the same extent of excessive inflammation as patients from the 1918 pandemic.7
There is some evidence to show that if a pandemic were to occur today, it would be individuals with robust immune systems who would be more likely to be affected because of hypercytokinemia. Thus, relatively healthy young and middle-aged adults might be the most susceptible to pulmonary complications.3,7,8 The young, very old, or those with compromised immune systems may be in danger as well, depending on other underlying complications.
Impact on Communities
Should a pandemic influenza overtake the United States today, communities and individuals will need to drastically rethink how they interact with the health care community. Depending on the severity of the pandemic, the numbers of sick and gravely sick could be overwhelming, devastating our ability to carry out normal life. Community and societal infrastructures (emergency responders, public services, delivery services, financial services, etc) will be severely threatened if employees were to be too sick to come to work. As people become sick and seek medical care, health care systems will quickly become overwhelmed and short-staffed.1
For hospitals, a pandemic will mean “business not as usual.” Surge plans will be instituted. Elective admissions will be cancelled. Currently, hospitalized patients will be evaluated for discharge to home or to other care facilities. Nontraditional wards within the hospital will be opened to cohort patients. Caregiver-to-patient ratios will be revised upward. Respiratory illnesses and complications will abound. Equipment, especially ventilators, will be in very short supply—and in very high demand.1,8 Hospitals will need to keep some beds available for patients with emergent needs other than influenza illness, whether from trauma, cardiac issues, or childbirth, among others. Patients will be triaged based on their level of illness; their need of intensive, supportive care; and, as the scarcity of resources increases, their likelihood of survival. Private physicians’ offices and community health care centers will need to take on the burden of addressing patients’ normal illnesses and complaints outside the confines of a hospital. Mental health facilities will need to gear up for a swell of patients as the emotional stressors increase. Hospitals will need to institute symptomatic surveillance of staff, and be ready to relieve those who show signs of illness.9 The hospital staff will suffer illness rates equal to or greater than the surrounding community, which will put an increased strain on the staff members who are healthy enough to come to work. With the need for resources and the desperate lack of those resources, the emotional toll on staff will be that much greater as they work with ill patients and interact with families struggling with loss. Some well staff may choose not to come to work because of concern for their families’ health and well-being. To address the staffing issues, hospitals will need to institute emergency credentialing for volunteers who wish to help. These volunteers could include traveling medical professionals, retired medical professionals, medical students, nurses, nursing students, and respiratory techs.6
The level of care for an influenza patient will be determined by a number of factors: the health of the patient, the severity of the influenza, and the number of resources (human, pharmaceutical, and health care) available to treat the patient.6
As hospitals will need to institute hospital surge plans, communities will need to assess their own surge capabilities. Communities’ surge capabilities are activities that bolster the response of a community’s health care facilities to an overwhelming event or disaster. In the event of a pandemic, this community/health care partnership could include triage centers (in-person or telephone) for those who have questions about symptoms, quarantine of people suspected to be infected with influenza, isolation of those known to be infected with influenza, or alternate care facilities (ACFs) for delivery of sub-acute care to patients too sick to be cared for at home, but not sick enough to be hospitalized. Hospitals and communities will need to work together to staff these ACFs with both medical and nonmedical personnel. ACFs will need to have some medical oversight and affiliation with a hospital for licensing purposes. Emergency medical service personnel and ambulance services will need to have altered transport orders, so that, based on triage, patients could be transported to a location that is most appropriate for their given symptoms and the ability of the health care system to care for them.6,8
Organizing around an event on the scale of a pandemic could be overwhelmingly daunting. The federal government, cognizant of the enormity of such events, has been developing and fostering a national infrastructure framework, under which the National Incident Management System (NIMS) was developed for managing events, local to nationwide in scope.10 The Hospital Incident Command System (HICS) is similar to the NIMS framework.11 The HICS is a standardized, hospital-based all-hazard incident management concept. It is a command structure that expands and contracts to meet the hospital’s response and recovery needs. It offers an approach to ensure consistency with the terminology and principles found in NIMS and Incident Command. HICS is a management tool and does not replace emergency plans, procedures, or policies currently in place at any hospital. The Joint Commission supports the use of HICS in its emergency preparedness standards, and because HICS is similar to NIMS, hospital personnel can interface seamlessly with community responders and unified command.
It is important for any hospital personnel, including respiratory therapists, to understand their role in HICS and the hospital’s command structure, when addressing pandemic preparedness. They will all have a role within HICS. Drills and exercises will emphasize pandemic planning, and HICS will help address areas needing improvement prior to the actual onset of a pandemic. Individual staff need to make sure they have a family plan in place as well, so that when an event occurs that requires a change in their normal family routine, families know what to do to keep themselves as safe as possible.
The best defense against the influenza is a vaccine to jump start the body’s immune response. A vaccine introduces antigenic material, similar to the target virus, allowing the body to start producing antibodies before actually being infected with the virus. Vaccines could take up to 6 months or longer to create, once the target viral strain has been identified.8 Antiviral drugs will be in limited supply and may not be all that effective, depending on the strain. Moral and ethical dilemmas abound on who should receive these antiviral and vaccine medications and when. Many different plans have been proposed, only to be torn apart. On July 23, 2008, the US Health and Human Services Department, along with the Department of Homeland Security, issued Vaccine Allocation Guidelines.12 These guidelines recommend providing vaccines to those people who: 1) maintain homeland and national security; 2) provide health care and community support services; 3) maintain critical infrastructure; and 4) are in the general population. Exactly how this will roll out when a pandemic occurs has yet to be determined. Being a part of the health care community working with high-risk patients puts health care workers and their families high on the priority list.
Respiratory caregivers will be on the forefront and in high demand but also at high risk, should a pandemic influenza ever take hold anywhere in the world. Knowing the larger social and cultural issues surrounding a pandemic will aid respiratory caregivers in understanding their need to prepare beforehand and their impact on people’s lives should this worldwide threat ever come to fruition.
Jennifer Lord, EMT-1, is an EMT, Norwalk Hospital, Norwalk, Conn; Tracy Evans, MS, MPH, is a contributing writer to RT. For further information, contact [email protected]
- Salinsky E. Tick-tock: preparing for the next influenza pandemic. National Health Policy Forum Background Paper. August. 27, 2004. Available at: [removed]www.nhpf.org/pdfs_bp/BP_PandemicFlu_08-27-04.pdf[/removed]. Accessed July 26, 2008.
- Petrosino AL. Cytokine storm and the influenza pandemic. 2005. Available at: www.cytokinestorm.com. Accessed July 13, 2008.
- New evidence of cytokine storm in avian flu cases. Available at: http://id-center.apic.org/cidrap/content/influenza.
- Flu treatment. Available at: www.pandemicreferenceguides.com/. Accessed July 26, 2008.
- Gruber PC, Gomersall C, Joynt G. Intensive care implications. April 24, 2006. Available at: www.aic.cuhk.edu.hk/web8/Avian%20flu%20-%20implications.htm. Accessed July 31, 2008.
- Lam C, Waldhorn R, Toner C, Inglesby T, O’Toole T. The prospect of using alternative medical care facilities in an influenza pandemic. UPMC Center for Biosecurity. Available at: www.upmc-biosecurity.org/website/resources/publications/2006_orig-articles/2006-12-15-alternativemedicalcarefacilities.html. Accessed July 26, 2008.
- Pellerin C. US researcher discovering what makes flu viruses lethal. Available at: www.america.gov/st/washfile-english/2006/Ocotber/200610021124091cnirellep0.6752283.html. Accessed July 26, 2008.
- Osterholm MT. Preparing for the next pandemic. New Engl J Med. 2005;352:1839-42.
- HHS pandemic influenza plan supplement 4 infection control. November 2004. Available at: [removed]www.hhs.gov/pandmeicflu/plan/sup4.htm[/removed]. Accessed July 13, 2008.
- Homeland Security, NRF Resource Center Web site. Available at: www.fema.gov/emergency/nrf. Accessed July 20, 2008.
- Center for HICS Education & Training. Available at: www.hicscenter.org/pages/index.php. Accessed July 20, 2008.
- HHS and DHS Announce Guidance on Pandemic Vaccination Allocation. Press release issued 7/23/08. Available at: [removed]www.hhs.gov/news/press/2008presss/07/2008080723a.html[/removed].