Influenza capable of causing a pandemic meets three criteria:

1. The virus is new, or "emerging,"
so humans have had little or no opportunity to build immunity to it.

2. It is virulent, causing significant illness and death.

3. It can be spread easily from person to person.¹

The A/H5N1 influenza virus meets two of the three criteria, fueling speculation that it may be the next pandemic influenza. The one unmet criteria is that it can’t yet pass easily from person to person.¹ Pandemic flu also comes in "waves." With each succeeding wave, there is the potential for the virus to grow more virulent.

The 1918 "Spanish Influenza" robbed more than 50 million people worldwide of their lives.² Within 5 months, it had reached the four corners of the earth.³ There were three waves in less than 2 years, and it grew more virulent with each wave.³ In her book The Coming Plague: Newly Emerging Diseases in a World Out of Balance, Laurie Garrett reported this on the Spanish Flu: "By October 1918 its strength was so great that people died with spectacular speed. There were reports of women boarding a New York Subway in Coney Island feeling little else than mild fatigue, and being found dead when the train pulled into Columbus Circle, some forty-five minutes later."³

If or when influenza comes, it could make the death toll of the Spanish flu look like peanuts, because it’s a different world now than in 1918. There are more people. There are more animals. The connection between the two is important. Avian flu and swine flu viruses have their origins in birds and pigs. Viruses are smart, and they’re not content to be static. They mutate constantly, seeming to know just which path to take to increased virulence. Even worse, they can sometimes figure out how to jump hosts. Jumping from one host to another can increase a virus’s virulence. As long as the avian flu stays with birds and the swine flu stays with the pigs, we’re okay. The moment the virus figures out how to jump from animal to human, it’s time to sit up and take notice. If the virus figures how to transmit from human to human efficiently, we could be in deep you-know-what.

In 1918, not many people were world travelers, and the modes of long-distance travel, ships and trains, moved much slower. Today, many of us think nothing of hopping a plane in the morning and finding ourselves halfway around the world by dinnertime. What if one person on a plane was infected with influenza? The virus can be transmitted before the victim is symptomatic. The plane’s air is constantly recirculated. How many people on that plane would turn up with the flu in the next few days? How many people would they transmit it to between disembarking the plane until they exhibited symptoms? And the people who caught it from those who traveled in the plane with that one infected person, how many people could they transmit it to . . . and on and on? Today, it wouldn’t take 5 months for influenza to circle the globe. Many countries could be infected in only a few days. The potential for a pandemic is mind-boggling.

Maybe it won’t happen. We’ve had false alarms before. But if it does? Can your facility afford to be unprepared? It bears taking this personally, because whether facilities are prepared could make the difference in whether your baby or your mother—or you—survive the attack of influenza.

Influenza, as a mass casualty event (MCE), falls under the category of "developing MCE," as opposed to a "sudden-impact MCE," such as explosions or bombings.2 A sudden-impact MCE is unpredictable, requires immediate response, and is concentrated in one area at one given time.2 With a developing MCE, such as an influenza pandemic or bioterrorism, the numbers of victims could continue to rise over a period of time.2 The volume of victims could quickly overwhelm hospitals, making supplies scarce.2 Fortunately, an influenza pandemic is a predictable event for which facilities can be prepared.2 Healthcare organizations and facilities around the world are doing just that, and the healthcare industry is heavily involved in such efforts, armed not only with products but education for infection control practitioners (ICPs) and others on the front line.

Premier Inc, Charlotte, NC, is one of those companies. Premier’s Influenza Task Force monitors issues relative to preparing for seasonal influenza as well as a pandemic influenza. "Ongoing issues that are monitored include seasonal vaccine availability and distribution, vaccination of high-risk groups, pandemic influenza alerts, emerging information on potential for avian flu transmission, and relevant updates or guidelines from the CDC and other government agencies," said Gina Pugliese, RN, MS, vice president, Premier Safety Institute.

An issue that’s controversial, noted Pugliese, is what kind of respiratory protection to stockpile for use in the event of pandemic influenza. "In 2005, The World Health Organization (WHO) and the U.S. Department of Health and Human Services (HHS) had taken the position that surgical masks are adequate for isolation from short-distance droplets, as is the case
of influenza, because there’s no evidence that the avian influenza transmits any differently than seasonal influenza. They recommended reser-ving N-95 respirators for use during short-range aerosol-generating procedures such as intubation.⁴

Pugliese told HPN that HHS recently released an update to the existing plan, "Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Health Care Settings During an Influenza Pandemic, October 2006,4,5 which led to widely diverging opinions, because "now they are recommending use of N-95 respirators for direct patient care in an influenza pandemic, terming this ‘prudent’ in case the pandemic is caused by a new influenza virus that may be transmitted by air as well as droplets. These new guidelines create a dilemma," explained Pugliese, "because you don’t know how many masks or N-95s to stockpile now. It appears that, because the governmental agencies couldn’t agree on the effectiveness of masks for airborne transmission, they have chosen to go with a higher level of protection. This raises serious issues of available supply of N-95s where they are needed most, ie, procedures like intubation and TB," said Pugliese.

Pugliese, an internationally respected infection control professional, noted that, in the meantime, infection control departments and practitioners need to have an influenza program in place. "There is much more to influenza planning than just respiratory protection. Thirty-six thousand people die from influenza every year. You can’t be prepared for a pandemic if you don’t already have an influenza program in place. It’s very important to teach cough etiquette and respirator etiquette. Healthcare worker immunization rates need to be improved. ICPs need to be part of a team to talk about controls, for example: How are healthcare workers going to be off work if a pandemic hits? Will there be liberal sick leave? How do you keep mask usage appropriate? Should you reuse masks if there’s a shortage?"

"Premier’s role is to educate members," explained Pugliese. "We bring members together to talk about the supply chain. We also can inform them as to where to get vaccines and other supplies. And when there’s a disaster, you pitch in and help whether they’re members or not."

To access Premier’s public resource materials on pandemic influenza preparedness, go to http:/www.premierinc.com/quality-safety/tools-services/safety/
news/2005/11/pandemic-influenza-11-30-05.jsp.

Knowledge is good, but wisdom, knowing how and when to apply knowledge, is better. Being educated as to the possibility of an epidemic or other public health disaster is vital; more important is recognizing what you’re seeing when you see it and being prepared to handle the crisis before it happens. Likely, emergency departments (EDs) will be among the first to realize something is happening beyond the norm.

Sharolyn Rhees Medina, MD, FACEP, director, clinical informatics, Picis Inc, Wakefield, MA, talked to HPN about being alert to unusual activity in the ED: "Early awareness and identification of unusual patterns of presenting illnesses are vital. The earlier an attack or epidemic is identified, the sooner steps can be taken to immunize susceptible populations, including care-givers, and treat the exposed but not yet symptomatic populace. Information that may limit the spread of an infectious process also can be widely disseminated to protect the general population."

Medina stressed the importance of having in place a "chain of command" for reporting suspicious spikes in symptoms and a well-defined follow-up mechanism, to facilitate early action. "Too often physicians and nurses notice a seemingly unusual uptick in certain disease presentations, but in most cases there is no widely disseminated protocol for alerting appropriate resources to a potential problem. When 200 people show up in the ED within 2 hours with a constellation of bizarre symptoms, anyone can figure it out, as in a chemical attack, for example. The challenge is to identify the slowly increasing number of patients presenting over a 1- to 2-week period of time with vaguer symptoms that may be a prodromal period to a significant bio-agent exposure."

Clearly, an information and surveillance system that can identify public health trends in real time would be useful in a pandemic, bioterrorism, or other dis-astrous event. Picis Inc. has developed such a system in their ED PulseCheck. Medina explained that ED Pulse-Check can assist in fulfilling ICPs’ need to be prepared for a disastrous event "by helping to increase the efficiency of the emergency department," which will aid in managing the surge capacity.

"With exceptional functionality in patient tracking, concurrent clinician documentation, and comprehensive order entry, ED PulseCheck assists department managers and caregivers in ensuring patient records are readily accessible," said Medina. "Powerful reports facilitate patient follow-up and analyze patient throughput to identify systemic bottlenecks. Analyzing patient loads based on time of day also permits ED and hospital administrators to adjust staffing levels and tailor their inpatient bed-management strategy to accommodate any shifts in normal patterns."

Another advantage of ED Pulse-Check is that it can track which caregivers are involved with a particular patient, making it easier to identify who needs to receive prophylaxis or vaccinations should a highly communicable disease be identified once the patient has left the ED.

"ED PulseCheck’s embedded Risk Management module provides recommendations and reminders to document specific actions tied to good elements of care," continued Medina. "This reference tool helps caregivers who may be new or find themselves in an unfamiliar situation. ED PulseCheck’s Risk Management assists clinicians by providing visual cues for important documentation points and evidence-based information about a wide variety of conditions and situations. The reporting tools in ED PulseCheck are powerful enough to query many different types of parameters that may be of interest to practitioners interested in analyzing disease patterns, yet are simple enough to use that a clinician with no programming or report-writing skills can craft individualized reports quickly."

Another component is Picis’ ED Biosurveillance module, which "allows for automatic pooling of de-identified data from multiple participating hospitals in a region, to allow for analysis of clusters of illnesses or disease according to their geographic locations."

Medina recommended three reports issued by the Institute of Medicine (http://www.iom.edu/CMS/3809/16107/35007.aspx), noting that these reports found that hospitals are not prepared to handle either daily emergencies or national disasters adequately. "Emergency department information systems help reduce overcrowding, hospital diversions, long wait times, etc, and are seen as one solution to this nationwide problem," averred Medina.

A concern for ICPs on the front line at any time, but particularly important during a pandemic, is disinfection of environmental surfaces and equipment, to prevent transmission of pathogens. Droplets from sneezing and coughing associated with influenza can contaminate the environment quickly and efficiently.

Biomist Power Sanitizing System

How environmental disinfection has been traditionally performed has its drawbacks, Robert Cook, vice president, Biomist Inc., Park Ridge, IL, told HPN. He believes Biomist has developed a more effective method. "Current surface-disinfection techniques are often time-consuming and ineffective, utilizing a ‘hit or miss’ approach with trigger-spray bottles and sponge or rag wipe-down that can spread or re-introduce germs."

"The Biomist Power Sanitizing System propels a nonflammable mist of concentrated alcohol up to 15 feet with a point-and-spray atomizer. Alcohol’s antimicrobial properties are well known, and our system eliminates its flammability by using CO2 to encase the alcohol vapor. Biomist Formula D2 is an EPA-approved hospital-grade disinfectant that’s tuberculocidal, virucidal, fungicidal, and is strong enough to kill Norovirus. It’s a pre-mixed solution of isopropyl alcohol and quaternary ammonium compounds. It dries in minutes, so no wiping or residual cleanup is required."

"The swirling mist penetrates into cracks and crevices where pathogens hide," explained Cook, "disinfecting areas beyond physical reach such as ceiling vents. Biomist Formula D2 is non-corrosive, so it’s perfect for disinfecting non-critical devices and sensitive electronic equipment like electrocardiogram machines, computers, telephones, and keyboards. Biomist is also safe for use in food-processing areas and cafeterias."

Cook highlighted Biomist’s value in a pandemic. "During a crisis, Biomist is the first line of defense in preventing the spread of bacteria and viruses through effective surface disinfection. Our system kills germs faster, more effectively, and with far less labor than any previous method. In 2 hours, over 4,000 square feet can be sprayed without exposing patients and staff to noxious chemicals, such as chlorines, aldehydes, or phenols. Emergency departments, patient rooms, waiting rooms, and other areas affected by a surge of humanity can be disinfected in less time with less labor. Staff that would otherwise be dedicated to surface disinfection can be re-allocated and used more productively elsewhere."

To see how Biomist works, go to www.biomistinc.com and click on "Watch presentation video."

"The possibility of a pandemic influenza outbreak appears to present the most likely biological incident risk for which ICPs need to be prepared," stated Spencer Fullerton, new product manager, Health Care Logistics, Circleville, OH. "Plans to address pandemic influenza need to include provisions for three key areas of response: isolation, protection, and treatment."

Health Care Logistics’ 15-Person
Infection Protection Kit

Fullerton explained that these three components can inhibit spread of influenza. "It is vital that plans include ways to keep healthy people from coming in contact with contaminated individuals or areas. It may be difficult to know who might carry an infection or what surfaces or environments may be contaminated; so, personal infection protection becomes an absolute requirement in a pandemic situation. Adequate protection will include components for sanitizing surfaces and hands, as well as personal protection provided by items such as face masks, vinyl gloves, and eye shields."

"Pandemic preparation plans should include methods for those who become infected to receive immediate medical observation and attention. These plans are best coordinated with local health and medical facilities. An elevated temperature is usually one of the first identifying symptoms. Providing for immediate access to disposable thermometers is one way to help identify that an individual may be in need of treatment."

Fullerton described Health Care Logistics’ new product, designed to fulfill ICPs’ needs in the event of pandemic influenza or other disasters. "When complete isolation from any contact is not possible yet the threat of infection is considered high, such as in the event of pandemic influenza, our 15-Person Infection Protection Kit provides basic yet critical supplies recommended by the CDC for personal protection against infection. The kits provide personal protection for up to 15 people for as many as 3 days."

The kits include the following:

• Emergency instructions

• 45 N-95 respirators

• 15 eye shield frames and 45 disposable eye shields

• 50 pairs of vinyl gloves

• 15 4-ounce containers of hand sanitizer

• 15 tissues and 6 biohazard bags

• 6 2-ounce bottles of SaniZide germicidal spray

• 15 disposable thermometers

• 5-gallon storage bucket

Fullerton continued: "The CDC and WHO recommend using N-95 face masks, vinyl gloves, eye protection, and hand and surface sanitizers when there is a risk of contact with the germs that may cause bird flu. For the full list of supplies and suggestions from the U.S. Government for preparation for pandemic flu, visit www.pandemicflu.gov."

To request a sample of Health Care Logistics’ 15-Person Infection Protection Kit, go to http://www.healthcarelogistics. com/mall/more.asp?fmmore=10346

Selecting a strong, comfortable medical glove related to the procedure or task at hand
is covered in Ansell’s Pandemic Event study guide.
Ansell has a full line of medical gloves to fit any circumstance.

Gloves are an important part of personal protection for ICPs and others in the event of pandemic flu, bio-terrorism, or other disasters. Ansell Healthcare, Red Bank, NJ, has released an article describing proper glove use during such situations, but it also provides good, solid information on how influenza develops and mutates, what conditions make it right for an influenza epidemic, how it’s transmitted, a bit of influenza history, and of course it discusses glove properties and how to select the glove appropriate to the situation. "Optimizing Glove Performance during a Pandemic Event Caused by Influenza A" is a self-study guide good for earning continuing education units. It can be accessed at http:www.ansellhealthcare.com/america/usa/ansellcares.htm. Educational materials on other topics, including bioterrorism, are available at this same web address.

5. Centers for Disease Control and Prevention. Interim guidance on planning for the use of surgical masks and respirators in health care settings during an influenza pandemic, October 2006. http://www.pandemicflu.gov/plan/healthcare/