Influenza Pandemic Presents Unique ChallengesWritten by DR. ANN PETERKA Wednesday, 07 November 2007 13:02
Regardless, the threat of a flu pandemic has hardly receded, and world health experts are in agreement that a pandemic is inevitable. It’s impossible to predict when the next pandemic will hit or what particular strain of virus will cause it, but at this point, the H5N1 avian influenza virus appears to be the most likely culprit. Since the virus began ravaging Asian poultry stocks in late 2003, it has infected nearly 300 people worldwide, killing more than half of them (as of April 2007), and more than 200 million birds have died from it or have been culled to prevent its spread. Bird flu is mainly a disease in animals, but the virus is constantly changing. Experts fear it could mutate into a form that can be passed easily among people, which could lead to a worldwide pandemic with the potential to kill millions.
The H5N1 avian influenza virus is circulating among birds in Asia, Africa, Europe, and the Middle East, and while efforts to stamp out the virus have been extensive, some countries are handling the situation more effectively than others. Indonesia, in particular, has struggled to contain the virus and leads the world in the number of human infections, with 94 reported infections and 74 deaths as of April 23, 2007. Bangladesh is another country that has had significant difficulty managing bird flu outbreaks. While no human cases have been reported in the country, the virus spread among poultry flocks on numerous farms in Spring 2007 despite massive culling and bans on the movement of chickens in areas with confirmed outbreaks.
While poultry deaths from H5N1 might not initially seem to be especially concerning, it’s important to note that ongoing poultry outbreaks allow the virus more opportunities to mutate. If the virus mutates into a form that is more easily transmitted between humans, the consequences could be devastating. Outbreaks among birds also increase the opportunity for human exposure. Human infections of H5N1 have generally been linked to contact with infected birds.
When you factor in certain societal characteristics, the threat of a worldwide pandemic becomes even more evident. In comparison to previous pandemics, such as the 1918-1919 pandemic of Spanish flu that led to more than 30 million deaths worldwide, our population is much larger, denser, and more mobile. Because of advances in medical care, we have an aging population that includes greater numbers of immuno-compromised hosts. For social and economic reasons, more women are working outside of the home, and consequently, more children than ever before are in daycare. We also travel much more extensively than previous populations, increasing the possibility of viruses being carried around the globe in a matter of weeks, as opposed to previous pandemics, which typically swept across the world in 6 to 9 months.
Although there have been no reported cases of H5N1 in the United States, it would be foolish to think that we’re not at risk of being struck by a pandemic. An incident in March 2007 served as a stark example of how easily pandemic flu could reach our shores. Passengers on a flight from Hong Kong to Newark were held on the plane for two hours after landing because a number of passengers appeared to be ill during the flight. Experts from the Centers for Disease Control and Prevention were dispatched to the plane to inspect the passengers. While they did not find any indications of a serious infectious disease such as H5N1, this false alarm raised fears of a pandemic among public health experts and business leaders alike.
Influenza Pandemic Presents Unique Challenges
It’s understandable why some contingency planners might think that emergency preparedness and pandemic preparedness go hand in hand. But, in reality, an influenza pandemic presents unique challenges to your organization and, thus, requires different preparedness strategies to address those challenges.
Natural disasters are typically short-lived events that strike one specific region, leaving unaffected regions with the ability to provide relief. A pandemic, on the other hand, is longer in duration and widespread, thereby stifling or precluding relief attempts. Likewise, absenteeism is likely to be higher and more prolonged during a pandemic compared to other emergencies. One recent report concluded that a severe flu pandemic would infect nearly 90 million Americans and require them to miss work for three weeks. Countless others would miss work to care for sick family members.
Clearly, then, a pandemic is not your "typical" emergency. As a U.S. Treasury Department official observed in congressional testimony last year:
"A firm cannot simply move to back-up facilities and restore operations, because it is likely those facilities are also experiencing challenges associated with the pandemic. Contingency planning must now take into consideration efforts to mitigate the spread of influenza within the firm or a department. Among the key issues for consideration are the stockpiling of masks, gloves and antiviral agents, additional hand washing stations for employees, and identifying and isolating employees who may be sick."
Providing medical interventions, while no simple task, gives employees both added protection and the confidence that it’s safe to report to work – which, in turn, helps ensure greater continuity of critical operations.
The following information can help contingency planners as they grapple with the important questions that arise when it comes to employee protection plans that make use of medical interventions.
Vaccination is regarded as the most important medical intervention for preventing influenza. In April, the Food and Drug Administration approved the first vaccine for use in protecting humans against the H5N1 influenza virus. The vaccine is already being stockpiled by the federal government and would be used if the strain of H5N1 mutated into a form that spread easily from person to person, leading to a pandemic.
Although the vaccine’s approval is an important development in the fight against bird flu, it has several drawbacks. The first is its limited efficacy. Results from a clinical trial show that the two-shot series of the vaccine appears to provide protection for only 45 percent of adults who received the highest dose. By comparison, seasonal flu shots, which are given in a single dose, typically provide protection for more than 90 percent of young, healthy adults. The bird flu vaccine requires two injections 28 days apart, which could slow the response during a fast-moving flu outbreak. FDA officials recognize the vaccine’s limitations, conceding that the vaccine is "an interim measure" until better ones can be developed.
Secondly, the vaccine will not be commercially available, so corporations will not have the option of developing a private stockpile for their employees. The federal government has purchased the vaccine for inclusion in the U.S. Strategic National Stockpile, which currently contains enough vaccine to fully immunize 3 million people. The government plans to buy enough for 20 million people.
Finally, and perhaps most importantly, the vaccine was developed using an early strain of the H5N1 virus. The vaccine that will target the specific strain of influenza that causes the next pandemic cannot be produced until the actual strain emerges and begins to spread. Experts say it could take 6 to 9 months to develop, manufacture, and distribute the tailored vaccine.
Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota and an expert on pandemic flu, summed up the role that vaccines should play in corporate preparedness plans when he stated, "Business preparedness must move forward assuming that influenza vaccines will not play a real role in the first 4 to 6 months of the next pandemic."
In the absence of an effective vaccine, antiviral medications represent the first line of defense against an influenza pandemic. When it comes to antivirals, the challenge is having the medications available when and where they are needed, and America’s employers are among the best equipped to make that happen. Corporations have the resources and infrastructure to purchase, store, and distribute prescription antivirals to employees while providing education about how to use them during a pandemic. The federal and state governments are currently stockpiling antiviral medications with the goal of purchasing enough medications to cover 25 percent of the U.S. population. Clearly, this leaves a majority of Americans without access to antivirals in the event of a pandemic, which makes corporate preparedness even more critical.
The following six steps provide a general overview of how a corporation can develop an antiviral distribution program.
Step 1: Determine who to cover
To begin, you will need to define your company’s "Business Critical Employees," which can be defined as those employees who are responsible for or play a supporting role to critical job functions. For every "Business Critical Employee," at least two back-up employees should be identified. Next, you will need to determine which "Business Critical Employees" can fulfill their job roles at home vs. those who must work on-site during a pandemic. Lastly, you should identify the functional areas that may need an increased number of employees. For example, security operations may need to be enhanced during a pandemic.
That said, when deciding which employees will receive antiviral medications, companies should weigh the importance of business continuity vs. employee protection. Keep in mind that making the medications available to all employees regardless of job responsibilities can not only serve to enhance trust and loyalty among your workforce but can also make for a smoother recovery following the pandemic. Those employees who may not be required to work during a pandemic will play an important role during the recovery period by helping to return operations to normal.
Another important factor to consider is that a pandemic will put incredible strain on the healthcare system. According to a report from the non-profit Trust for America’s Health, half of the states would run out of hospital beds within two weeks of a moderate flu outbreak, and 40 states would experience a nurse shortage. In short, employee protection plans must address how companies will assist their employees when access to routine healthcare is not available.
Step 2: Assess the number of treatment courses that will be needed
Although determining the number of treatment courses to provide for employees is not an exact science, companies can get started by deciding if they will provide antivirals for prevention, treatment, or both. Based on that decision, companies should decide the length of time they would like their employees to receive and use antiviral medications. While there is no hard and fast rule about when employees should begin using antiviral medications, companies should plan to rely on the guidance of the Centers for Disease Control and Prevention, the World Health Organization, and local health authorities.
Step 3: Facilitate physician consultations
Antivirals are prescription medications that must be prescribed by a physician. Medical consultations for employees can be implemented in a variety of ways, and they should be arranged well before the start of a pandemic because the strain on the healthcare system immediately before and during a pandemic may make it difficult to identify physicians who are able to conduct consultations. When determining the best method for facilitating the consultations, companies need to balance their resources and needs, and the number of employees and geographic locations should factor heavily into the decision. For companies that employ thousands of individuals dispersed across the country, using a healthcare provider that has a national network of physicians is often the most effective route.
Step 4: ‘Order’ antiviral treatment courses
Antivirals cannot be purchased directly from pharmaceutical companies. Companies can order antivirals from a pharmaceutical distributor or wholesaler, a pharmacy benefits manager (PBM) or a local pharmacy. You can find a list of authorized distributors at www.PandemicToolkit.com.
Step 5: Educate your employees
Ideally, companies should begin their education efforts by building awareness of pandemic flu and the disease control measures that can help employees avoid getting sick in the first place. Education campaigns should be implemented to remind employees of the importance of workplace etiquette, such as covering your cough and staying home when sick, to control the spread of illness.
Once a foundation of understanding of pandemic influenza has been established, companies must ensure that their workforce has the knowledge necessary to use antiviral medications responsibly. Multiple mediums should be used to communicate information about the indications and proper use of antivirals. These could include memos and videos from senior management, direct mail, e-mails, an employee information hotline, and online training courses. At least one of these education tools should be mandatory to ensure compliance.
Step 6: Distribute the antivirals
Distribution can be centralized or decentralized. For centralized distribution, companies develop a central stockpile of antivirals that employees can access when they report to work. This method has several downsides. First, employees may be unable or unwilling to visit the work site to obtain their share of medications. Second, employees who are ill could potentially spread the infection to others when they report to the work site to receive their allotment of antivirals. Third, storing the product at a central location could pose a security risk during a pandemic. Because of these risks, companies that elect to centralize their distribution should plan to do so before the start of a pandemic.
Decentralized distribution involves shipping the product to other locations. Forming a partnership with a pharmacy benefit manager (PBM) is one way to implement this distribution method. PBMs are able to stock, secure, and distribute medications to individuals at their homes. A company would supply the PBM with a list of employees who have completed the necessary educational programs and have received a prescription following their physician consultation. The PBM then distributes the antivirals to employees before a pandemic hits.
When finalizing their distribution plans, companies should keep in mind that pandemics are inherently unpredictable. Whether distribution is centralized or decentralized, making antivirals available to employees before the pandemic hits can help to mitigate against the distribution problems that are likely to develop during a pandemic as a result of a strained healthcare system, limited resources, and fractured infrastructure. Employees should be advised to consult with a medical practitioner for guidance about using antivirals prior to use.
The process of developing plans to protect your employees during a pandemic is undeniably complex. Unfortunately, that complexity has led to complacency among many businesses. Nevertheless, it remains a given that the key to protecting your business during a pandemic is safeguarding your organization’s most important asset: your people.
Dr. Ann Peterka is the director of Employee Health Services for Roche. With U.S. headquarters in Nutley, N.J., the Roche Group is one of the world’s leading research-oriented healthcare groups with core businesses in pharmaceuticals and diagnostics. In March 2007, Roche hosted a seminar on pandemic preparedness for more than 100 manufacturers and other business partners at its U.S. headquarters.
"Appeared in DRJ's Summer 2007 Issue"