- It has happened before, and it will happen again.

- Death rates may be very low, and usually are. But the H5N1 virus in it's current form has roughly a 25-50% human mortality rate with animal to human transmission. Nobody knows what it will be in human to human pandemic form.

- The most depressing conference I ever attended: "Dealing with the dead from a flu pandemic"

- Full employment for estate and probate attorneys!

- Funeral homes use "just in time" delivery, too. Crematory capacity is also limited, as is cemetery space. Refrigeration will be required. Plan on a long wait. But the dead won't be burned on pyres or bulldozed into trenches. They will be treated respectfully and accounted for.

- To the extent vaccines or drugs are useful, the means exist to distribute them quite efficiently. Insuring production capacity is still a work in progress. identifying the strain of flu causing the pandemic in sufficient time, with sufficient accuracy, is the core problem in producing vaccines.

- Treating flu victims is largely supportive. There is no pill that really fights viral diseases like influenza.

- The limiting factor for the health care facilities is the number of ventilators (machines that breathe for you or help you breathe) available. Hospitals are otherwise better prepared than you might think for surges, isolation, etc.

- Frequent hand washing and simple face masks offer a good deal of protection. Get your masks early, since they will be very hard to find at retail. N95 is excellent, N100 is overkill, and simple cloth or paper will do.

- The flu is most dangerous for the young, elderly, ill and immune-compromised. But the brutal, global, "Spanish" flu pandemic following WWI seemed to kill healthy young adults disproportionately, while the elderly seemed to enjoy partial immunity due to some prior epidemic in their youth.

- True "home nursing" of the seriously ill is pretty much a lost art, families are smaller, with more working members, and people will struggle to care for ill family members at home.

- Think about day care. Schools are likely to be closed.

- Most people cannot afford to stay home from work for the several weeks to a few months it takes for an epidemic to run its main course. For many, holing up just isn't an option. Others will find they have no jobs. Unemployment will be a major issue.

- Truly essential infrastructure and commerce is likely to be maintained, in large part because such activities don't often involve direct contact with a lot of other people. Moreover, everyone doesn't get sick all at once. Other things may not fare so well, causing considerable disruption and inconvenience.

- The way you do business is likely to be quite different. Browsing the aisles at the local grocery may be out. You might find yourself phoning or e-mailing a list, and picking up your bagged order by appointment. There are a variety of plans out there, but nobody really knows.

- Many of the worst problems will be unnecessary and avoidable, driven by panic, misinformation, fear, lack of preparedness, and social upheaval.

Maybe this will stimulate some useful discussion. It's not really useful by itself. Sorry, I'm just sick and illness and disaster is on my mind, I suppose.

Jeff

i believe that you are correct. My understanding is that the main cause of mortality was bacterial pneumonia, but only in conjunction with the debilitating effects of viral influenza on the lungs. These bacteria are already present in your upper airway, and thus need not be communicated to you. Your immune system keeps them in check, unless it gets overwhelmed by the flu, then they colonize your lungs.

Therefore, I suppose a future influenza epidemic could take the same course. The cause of death is respiratory failure from opportunistic pneumonia. But the precipitating event is the influenza virus.

As I mentioned, a main limiting factor in saving patients from this fate is the availability of respiratory support in the form of ventilators. There are (or were) already national stockpiles of antibiotic medicines, which will help a lot, and which were, of course, unavailable in 1918.

Jeff

I should add that, although I've had a lot of briefings and training in dealing specifically with this, and have seen some of the planning and forecast documents, I am certainly not any sort of expert on this subject.

Compounded, in a great many places, by reduced quantity and quality of diet caused by a several horrible winters and harvests back to back.

The question about mortality among "healthy young men" that I haven't been able to find is what percentage were WWI vets? It is possible that trace exposure to blister agents might have had some effect on their their death rate.

My understanding is that the death rate in each age cohort was about the same for males and females, controlling for the additional risk to pregnant women. Finding out exactly why so many otherwise healthy adults died in the Spanish Flu has been a subject of considerable interest for many years.

Of course, military service can be debilitating all by itself, and troop concentrations and movements are thought to have influenced the pattern of the epidemic, but I don't believe current thinking is that incidents to military service explain the unusual "W" shaped, instead of the usual "U" shaped, distribution of mortality. (a peak on the left for infants, a peak in the middle for adults, and a peak on the right for the elderly, where x = increasing age and y = increasing death rates)

Consider why there would be interest in that, especially if it were the case that it was preferentially debilitating or lethal to adult males. Not all research into influenza has been based on benign motives.

Jeff

That sounds likely. These things are complex, and likely to be quite different each time, rather than replays of what happened before. Nonetheless, the Spanish Flu serves as a sort of worst case planning model today.

jeff

Well, I think it's worthwhile to think about this. The general opinion among experts seems to be that it's probably a matter of "when" not "if."

The SARS outbreak affected a lot of Asian countries, and hit some regions in Canada as well. That's a product of international air travel as much as anything. But we got a rude awakening, and a fair amount of national and local preps have been put in place as a result.

I don't know what sort of preps you are seeing in the USA.

I know that a lot of companies up here have been planning how they will keep business going with 40% of the workforce absent. And I recall getting a mail-out poster from the local health authority, advising people how to prepare for a pandemic. Much of it is the standard stuff, but it gets people thinking (I hope).

The worst thing is, a pandemic will come in waves, possibly over a 6-month period IIRC. It's hard to bug-in for 6 months, maintaining perfect isolation, in any realistic way.

I believe that part of the reason why the 1918 flu had such a predilection for the relatively young adults was actually because their immune response WAS strong. Patients drowned in their own fluids from the secretions that built up in their lungs. Googling around on "cytokine storm" and influenza will bring up some good information. At any rate, with some viruses, including avian flu to the best of my knowledge, it may not be the virus per se that is the problem, but rather the robust immune response (cytokine storm) that causes the problems.

Eric

See
http://www.bioethicsinstitute.org/web/module/press/pressid/104/interior.asp
Our bioethicists are thinking about this very issue. If people are to survive, we'll need truck drivers to get food to the surviving masses, grocery store workers, utility workers, and communications personnel. So it's not just doctors, firefighters, and cops that will be given whatever treatment there is. As emergency communicators, my wife and I could be on the list of those who live. Or maybe not. Who can tell?

I have to disagree, politely, with a couple points-

Ventilators are not in short supply, practically every home oxygen company in the country that does home ventilator care has them readily available because they are possible high revenue patients. And they all require a minimal battery backup, so they are plugged in round the clock, checked annually by the maker, and ready to go on a patient at a moment's notice.

Now it's possible the the big behometh ventilators are in short supply in hospitals, but then again, they are so expensive that acute care folks try to transition vent patients to the home as soon as possible, and the fact that the DRG's that determine their reimbursement often mandates a quick turnaround to lesser levels of care.

BiPap therapy (a sleep apnea device that has also been used for non-invasive ventilation) is also very prevalent. At one time, I recall they used them in third world countries as an alternative to intubating for short term needs. I think I once read where a hospital in Thailand used them to treat people bitten by pit vipers (may have the snake wrong) since the venom caused either the throat to swell, or lung function/muscle response issues, I can't remember.......

Last worst case scenario is you bag them (use an ambu-bag manually until mechanical ventilation is available). I personally experienced this during a power failure, people taking shifts to bag the vent dependent patient.

And home care is alive and well, the only problem there is a nursing shortage, not the capacity for care. In fact, the very phenomenon that you describe (smaller families, all parents working, etc.) has created a home care boom, especially with forecasters preparing for the aging baby boomers, who will presumably shun end of life institutional care for staying in their homes. And the nursing shortage will turn to a glut, like it does every several years, as more foreign born nurses are recruited to work here, amongst other things.

One school of thought is since there are so many opportunities for women now, that they no longer seek the traditional nursing school path in the USA. I am curious if others agree.

What it has also created, through expediency, is a "technician" level of care since the technology has taken away the need for RN's to monitor every aspect. In fact, most long term care patients (ALS, MS, MDA, pick your malady) are typically cared for by LPN/LVN level practitioners, in my experience. Which there are plenty of.

If I'm off the point here, my apologies, I agree the threat is real, but those specific points may not be as dire........

I think the speed--i.e. the lack of it--in producing vaccines will create various problems. Obviously, just the fact that it usually takes 9-12 months to even produce a normal year's batch of seasonal vaccine means that people won't be able to rely on a vaccine for quite a while. That may force us to rely heavily on anti-virals but I fear that the pandemic flu would quickly develop resistance before any vaccine is ready.

And with so many people getting infected during a pandemic, that just increases the chance that the virus will mutate enough to make a vaccine that was started 9 months ago to be less than optimal by the time there's a significant inventory built up.

An efficient distribution network will still be at the mercy of production limits. When the FDA shut down that Glasgow vaccine manufacturing plant a few years ago, suddenly cutting off a huge chunk of our normal flu vaccine supply, there was quite a bit of talk about who should get the limited supply. Should first responders get first crack? The most vulnerable sub-populations? If the public has a perception (which may not be factual) of a lot of people dying then who knows what kind of panic could surround any sort of vaccination campaign.

And there is not that much vaccine producing capacity. What happens when the entire human population on the planet is suddenly clamoring for vaccine? What do we in the developed world do about countries which are too impoverished to effectively purchase/produce/distribute a vaccine?

Heaven forbid that the pandemic strain actually turns out not to be easily cultured. Some people love to criticize seasonal vaccines when they aren't an exact match. That's mostly because of the long lead time between the start of production and when flu season actually hits, but another major factor is whether a particular strain can even be cultured effectively. Some strains are notoriously difficult to produce so a compromise is to select a different but related strain and hope that there's some crossover protection.

If--that's a huge if--some H5N1 strain turns out to be the next pandemic disease to hit humanity, at least there's one FDA approved vaccine out there. It certainly won't be an exact match to the pandemic strain, but it may be close enough to give partial immunity until a better vaccine can be produced.

Cory Doctorow (of BoingBoing fame) wrote an interesting short sf story called "When sysadmins ruled the earth", based on the premise that the people running the server farms will be protected from global disaster, since their work environment would be sealed off from everyone else, and have generators, etc. to weather the crisis.

You can download the story as a series of readings here.

Thank you for the interesting comments.

The CDC uses the following planning assumptions:

In a moderate flu pandemic, 64,875 Americans will require mechanical ventilation, and in a severe flu pandemic 745,500 will.

There are currently a little over 100,000 ventilators on hand in the entire country. Most of them are already in use on any given day.

The Strategic National Stockpile contains about 6,000 ventilators, but has been acquiring more. The SNS is the nation's main resource for large scale surge medical supplies, equipment, and medications in the event of a national medical emergency.

What we are discussing, for planning purposes, is mechanical ventilation capable of controlling rate, tidal volume and PEEP. Some of the possible alternatives you describe sound interesting, but are not the same thing, with the same capacities, as those used for planning purposes. Maybe somebody with more expertise will weigh in.

How many people did you need to bag one patient, and for how long? Depending on pulmonary and anatomic resistance, you can get pretty tired, pretty quick. Around the clock bagging will take a lot of people, and it is not very consistent or reliable, but it can be done.

My point exactly. There is a shortage. Moreover, many nurses currently working in home health care are expected to be drawn into acute or custodial care settings to meet acute surge demand and absenteeism shortfalls. People today lack the skills, resources and ability to provide lay "home nursing" as was often done in the past.
I agree.

Jeff

Let's also keep in mind that different viral infections manifest varying symptoms, so each strain has it's own peculiar epidemiology. H5N1 seems to be more fatal/devastating to people with the healthiest and strongest immune systems, because this virus overstimulates the body's immune system response, and the various components that are triggered (such as histamine response) overwhelm the cardio-pulminary and respiratory systems. Those whose immune response is diminished, as with older but not yet geriatric victims, seem to have the best rate of survival. Males in their twenties seem to be at greatest risk.

I still contend that there are loads of portable home ventilators sitting on shelves in nearly every community in the US that are probably not in that 100,000 figure. But I would have to agree- there aren't 750,000 of anything sitting out there if that is the number we're working with.

Regardless, for planning purposes, when the supplies run out, you would hope the call would go out for home vents, Bipap's, and any other device that has been used for this purpose however arcane and untested. That was my reason for including my thoughts on the alternatives. Same with bagging- it was, I recall, 4 people over 12 hours, and yes, very difficult. But the patient lived, and none of the four were of any medical discipline, all family members.

I may be wrong, but I would also submit that home care nursing is a different critter, and just like you wouldn't send a med surg nurse to a psych ward, you wouldn't send a home care or nursing home nurse to a hospital, or an acute care nurse to the home. Different skill sets and training. Another reason why the lesser disciplines have continually taken on a larger role in all settings, besides insurer mandates and the obvious shortage. But I may be splitting hairs here.

When nurses complete their CEU's to maintain their licenses, I think it's safe to say that they would probably lean towards continuing education specific to their discipline? So perhaps they should be encouraged to take CEU's specific to these scenarios?

That's not to say they wouldn't answer the call if asked, just wonder if there would be the bang for the buck, so to speak. Certainly anyone with training would be better than nothing at all. However, they have a patient load that would now be without licensed caregivers if they all reported to acute care.

In a large percentage of home care cases, there are family members that are the primary caregivers, because our insurance industry doesn't pay for around the clock care, so I am of the mindset that there are more lay caregivers out there than ever before. Especially since people are living longer.

Yikes, 750,000- it's staggering, eh? My original post seems kinda naive in retrospect.