Wednesday, April 29, 2009

All Swine, No Flu?

You didn’t think that the federal government would come to the dance without a partner, did you? For the past few months, my office has been involved in CDC preparedness for an influenza pandemic. I can’t really get into the details, but given recent developments I thought I’d share some observations and insights about pandemic planning as an FYI with you (both of you who still read this blog that is).


Here is the deal: The feds have actually been preparing for a pandemic influenza for a long time. 9/11 obviously kicked things into a fury, and ever since then there has been quite a bit of funding available to the states for all sorts of disaster preparedness activities.


Back in about 2004, the feds realized that they needed to get a solid plan in place for vaccine distribution policies that incorporated not only input from expert stakeholders and policymakers, but also from the public, because questions about who gets to be first in line for vaccines are really issues of discussion for all of us, not just the National Vaccine Advisory Committee or Homeland Security. Thus, the feds convened a series of discussions across the country soliciting input from members of the public, stakeholders, experts, and various other policymakers about what federal guidance should be on vaccine allocation prioritization.


Although its only federal “guidance” – this form of guidance comes with a big stick, because even though in theory the states call the shots on managing public health emergencies in their own jurisdictions, the feds have a great deal of influence and control on actual stockpiles and distribution of vaccines. Long story short, the federal guidance – a combination of public, stakeholder, and expert input – states that allocating vaccines during a pandemic should be done in a way that prioritizes the maintenance of critical infrastructure first. In a nutshell, this means that – in the feds’ view - folks who work in emergency management or have important infrastructure or safety and security responsibilities should be receiving vaccines before your elderly grandparent or 2 year old son or daughter does. Hurricane Katrina, when emergency management crumbled just as fast as the levees did, just reinforced the importance of prioritizing the maintenance of critical infrastructure following a disaster. Uniform implementation across states is particularly key considering that if states had different policies on vaccine distribution, people might start moving between states to get vaccines during a pandemic, which would just add to the chaos.


There has also been quite a bit of planning done on what one would call “social distancing” policies, which is a pleasant euphemism for implementing strict community control policies that would mitigate the spread of a pandemic. When do you close schools? Bar church gatherings? Impose curfews? Force people to telecommute from work? Issue food rationing plans? Again, with the input of massive amounts of mathematical modeling and some say from experts and the business community, a fair amount of planning has been done in regards to preparing for such contingencies, with SARS being a good flash in the pan preview of coming events.


So, this leads to the question of what sort of pandemic planning has YET to be done? Unfortunately, it’s a doozy: there is little guidance and policy on any level on what is called “altered standards of care.” Altered standards of care refers to situations in which, during a pandemic, hospitals are overflowing, vaccines are rare or non-existent, and 2/3 of health care workers have either perished or have run for the hills. One critical question is: who gets prioritized for medical care in these situations? You’ve got a pregnant woman in labor, a 10 year old kid with significant influenza symptoms, and a cop who just got shot trying to stop rogues from looting a grocery store. Who should get treatment from the only available physician at the hospital first? The flip side of the coin is a healthcare delivery question: If you’re a pregnant woman in labor and there are no physicians available to help you, who should deliver your child? A nurse’s assistant? A 1st year med student from the local college who just finished his first OB/GYN course? Important questions, with few answers out there. Although many individual hospitals do have plans in place for such disastrous scenarios, many others do not.


Well, at this point its clear that there is a lot of media generated hysteria out there (bolstered with a fair amount of xenophobia) about this current epidemic. Lets pray that we get this thing in control fast, and I believe that we will in fact do that and this outbreak will be brought under control soon. These are just my 2 cents and I hope it somehow contributes to a better understanding of the overall context and what plans have been made and what plans have yet to be made. Stay safe everyone.