Pandemic Influenza: A 2008 Plan

Influenza is a severe respiratory infection that is associated with excess mortality, especially in the elderly or debilitated among us. During a pandemic year e.g. 1918, 1957 or1968, there is worldwide disease with novel strains. Excess mortality on anastounding scale occurred in 1918-1919. The 500,000 deaths in the continental United States rivaled the U.S. Civil War in gross mortality.

Initial plans to provide for pandemic care are focused on vaccines and antivirals. (1) It is presumed that a vaccine would take six months to develop. It is unclear whether an antiviral would be effective against a strain of virus that is unknown currently.

There are features of the U.S. healthcare system that suggest we are ill-prepared for such an event. The infrastructure of modern hospitals has been diminished over the years. The evolution of outpatient surgery and endoscopy as well as the development of outpatient centers for the infusion of chemotherapy and antibiotics have all been associated with a smaller infrastructure to handle inpatient activities. Managed care has contributed to this pressure. This results in fewer doctors and fewer hospital beds that could be dedicated to pandemic medical care. A recently published Dutch plan allowed for a comparison of these issues. (2) The Dutch system had approximately four times the number of hospital beds than a comparison US hospital.(3) Hospital beds alone will not solve this problem.  We would likely need10 times the current number of ICU ventilators to manage the projected demand.(4)

The hospitalist movement now has over 20,000 in-hospital physicians doing “primary care” limited to hospitals. This has split the care of patients between inpatient and out patient in recent years. We no longer have a community of medical providers that have one central goal in mind. The outpatient doctors are no longer associated with the hospital in an organized way. Medical providers other than inpatient doctors will be needed to handle an emergency such as pandemic influenza.

Until recently we had doubts about what types of medical care would be most needed in a pandemic.   TheNIH supplied this critical piece of information. (5) On reviewing over 8,000autopsies from 1918-1919, they found evidence of bacterial pneumonia in 94% of cases. This means that hydration and intravenous antibiotics will be crucial in a pandemic. We will need a place to deliver this and it will not be thehospital. We need to assure that this care can be delivered in a timely fashionif we are to minimize the need for hospital respiratory support (ventilators).This is possible with early treatment of dehydration and early intervention for secondary bacterial infections. (6)

The Medical Association of Atlanta has worked with local and state officials to evaluate pandemic care and estimate the outpatient surge capacity for a pandemic. An outpatient infusion center could provide an alternative to an overwhelmed hospital. (4)  It would require medical manpower, logistical support, integration with EMS and assistance from local government.

We have received preliminary evaluation from local hospital, EMS and government authorities indicating that this is a feasible option. We are pursuing  community based primary care physicians toassist with this plan. We have the guidance of the Georgia Pandemic Influenza Coordinating Committee. We will be  implementing this plan at North Fulton Regional Hospital and developing guidelines that can be shared with other hospitals.

                                          References

1) Osterholm, M. Preparing for the Next Pandemic. N Engl J Med 2005; 552: 1839-1842.

2) Nap RE, Andriessen MPHM, Meesen NEL, van der Werf TS.Pandemic Influenza and hospital resources. Emerg Infect Dis. 2007; 13: 1714-9.

3) Dailey, MP. Hospital resources for pandemic influenza(letter). Emerg Infect Dis. 2008;14:512.

4) Dailey,MP. Pandemic influenza and community medical care. South Med J 2008; 101(2):215.

5) Morens  DM,Taubenberger JK, Fauci  AS.Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness. J Infect Dis 2008; 198:962–70.

6) Rivers E, Nguyen B, et al. Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock. N Engl J Med.2001; 345: 1368-1377.

Michael P Dailey MD
November 2008