SARS And H5N1: The Precautionary PrincipleWhile we’re still in week 3, and looking at getting the job done there’s an important piece of this we need to get out on the table, and very relevant for answering the question “What do I need to succeed in communicating the importance of preparing for a pandemic?” It’s to take a look at the virus we know is out there, H5N1, and make sure it is central to our thinking. This is a nasty, vicious killer of young people (90% of H5N1 deaths are less than 40 years old), and while we do not know that it is the next pandemic virus, no one can assure us that it is not. Mutations are a normal part of viral evolution, and the virus has changed since 1997 when it appeared, and 2003 when it reappeared, in Hong Kong. The next set of mutations can set off events we’d rather not think about, let alone experience. After all, the 1918 pandemic was bad enough with a 2.5% case fatality rate, but H5N1 has a 61% case fatality rate overall (80% in Indonesia). Those are staggering numbers to consider and comprehend. Now, isn’t that just an alarmist way of looking at current events? isn’t it true that we don’t know for a fact that H5N1 will be the next pandemic virus? Well, here’s the thing. H5N1 is out there, and it is not going away because it’s established itself in the bird and animal population (cats in Indonesia are not excluded from this virus, and there’s speculation that they may have some undefined role in viral spread). Each human exposure is another chance for viral mutation. And we have an important precedent to look at, both from Hong Kong and Ontario. I am, of course, referring to SARS. And here, we have a blue ribbon review of what happened in Canada when SARS broke out, what was done, and what could have been done better.
Here’s an excerpt:
There were some specifics from the report that need highlighting (vol 1, p.16):
Here’s more on the precautionary principle (page 10):
H5N1 is a real threat. Robert Webster and Elena Govorkova , writing in the New England Journal of Medicine, said
So, given what we know about the potential threat of H5N1 (which is considerable), and mindful of the precautionary principle, as well as the duty to inform, does it not make sense to prepare for worst case as well as mild case scenarios? It is in this context that discussion of how to stockpile (including suggestions of how long, and what, to stockpile, including medicines), and folding pandemic preparation into an all-hazards approach run into stormy weather. Planning for a worst case scenario ought to cover mild case scenarios and assist all-hazard preparation. Planning for a mild case scenario does no such thing. Mild scenarios do not consider loss of electricity, for one, or mass casualty events, nor do they consider the effect of illness on a vulnerable JIT economy. We will not be closing the schools for mild events (though they may close on their own when parents don’t send their kids – and don’t ever underestimate parents). And while it is true that we can not predict the next pandemic, or whether H5N1 is the next pandemic virus, the precautionary principle suggests treating H5N1 as if it is. After all, that’s why there’s such interest in this topic in the first place. Let’s acknowledge it and move forward with that in mind. After all, preparing for H5N1 prepares for any pandemic we get.
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Well Greg,
Posted June 9th, 2007 at 5:34 pmYou coaxed me out with this post. Excellent. Kudos to you. Now lets see who is still out there listening.
Greg, exceptionally well stated. Thank you!
Posted June 9th, 2007 at 5:51 pmI’m glad to see you come to my side of the fence.
The cliche -
Plan for the worst (case scenario), and hope for the best.
is a better strategy than the curent one dictated by the Admiral
Plan for the best (case scenario), and pray for nothing to happen.
Posted June 9th, 2007 at 7:21 pmDear Mr. Secretary,
This comment is intended to address the issue of getting the job done.
After pandemic outbreak hospitals and outpatient medical clinics will be overwhelmed with sick and dying patients. Access to these facilities will be extremely limited. Supplies of everything from latex gloves to IV tubing will become scarce very quickly even with ramped up production by manufacturers. As you are aware, the US DHHS PIP from Nov2005 projects that 90 million Americans will become ill with influenza during the pandemic. About 11% will require hospital treatment, 50% will require outpatient treatment and the remainder will be treated at home without formal medical intervention. While I think these are rather optimistic assumptions, the fact remains that pre-pandemic your departments own projections state that about 80 million Americans will be treated at home with or without their physician’s assistance.
Practically speaking then, the burden of care for most of our citizens that contract influenza will be born by their family members and friends, not the medical establishment. The US DHHS PIP recognizes this fact but the plan provides no guidelines for how our citizens should provide this care. Access to medical care in the US is excellent today. If someone becomes even mildly ill, they are able to seek treatment for it from a medical professional. During pandemic conditions however, this option may be denied for many moderately and even critically ill people for a variety of reasons. Given this probability, I have focused my work in the pandemic mitigation area by working to help people with no formal medical training to provide good home care to their relatives and friends ill with pandemic influenza.
Simply put, good home care can never achieve the outcomes we expect today from a fully setup and staffed hospital. However, good home care is far and away preferable to poor home care or no care. Providing good home care is neither complex nor expensive. The supplies needed to accomplish this level of care are readily available in the grocery, hardware, and drug stores nationwide. The cost for consumers to purchase the necessary supplies to provide good home care for everyone in their family is affordable for almost all Americans. What is lacking is authoritative guidance on what to buy and how to use it effectively. In this regard, I have written a booklet that provides this type of advice and guidance and made it available to everyone as a download from the www.birdflumanual.co… website which I invite you to visit. The booklet is entitled Good Home Influenza Care.
While this work may not be something the US DHHS would use to provide health guidance to US citizens, at the very least it represents a model that can be used by the department to develop its own guidance. The information contained in a booklet like this lends itself to distribution by various means. Of course printed copies will be very important for consumers to have on hand during the pandemic for use as a medical care guide. Since the pandemic will touch virtually every American family, consideration should be given for a booklet of this nature to be mailed to all heads of household for them to have. This information could also be produced as a series of video broadcasts that teach the consumer how to perform the simple medical procedures found in the booklet. These teaching videos could also be used to help consumers recognize the signs and symptoms of influenza and its complications and provide them with simple remedies whose judicious employment early in the course of the disease can be expected to improve outcomes for people treated in the home setting.
The cost of producing, printing, and distributing the booklets and videos would be considerable but well within the funds available for pandemic mitigation. The very fact that the US DHHS thought it important for all Americans to receive a booklet like this would help to increase public awareness significantly. The educational videos could be made available to all public broadcast stations nationwide as well as on the department’s website for download. RSS feeds that teach the same material as provided in the videos would also be a simple an inexpensive means to get this vital information in the hands of the people. The distribution of the booklet and the availability of the downloadable videos and RSS feeds could be widely publicized by the department prior to and concurrent with their distribution. This would also help to advance the public’s awareness of the coming pandemic. These announcements should suggest that consumers place the document in a safe place for future reference even if they do not plan to read them now
Sincerely,
Grattan Woodson, MD
Posted June 9th, 2007 at 7:48 pmDr. Greg. Without a shadow of doubt, a superb piece of writing that should be copied and framed in every Regulator’s office, in all countries of the world.
It’s quite simple really. The truth, the whole truth and nothing but the truth, even if it hurts.
Never, ever underestimate the intelligence of the people who pay your wages.
Posted June 9th, 2007 at 8:11 pmWe all know what the HHS is afraid of: don’t rock the economy boat until it is needed i.e. until we are sure there is a pandemic.
What the HHS doesn’t understand is that panic is caused by lack of information, or misinformation. The misinformation campaign that has been going on for the last few years will multiply the inevitable panic many times over.
What is needed is clear education BEFORE a pandemic, and when the world knows that a pandemic will impact us less than any other nation, then we will be coming out ahead.
As usual, bureaucrats are focused only on fighting the last battle (how SARS shocked the economy in Canada and Asia). What is missed is that SARS was a surprise, with zero preparation, and obviously people panicked. There is no excuse to cause the anticipated pandemic to do the same damage to our economy by lack of imagination and the trepidation of our leaders.
www.hhs.gov/agencies…
Acting Deputy Secretary HHS Speech “Preparing For A Pandemic” in Australia
Fourth, preparedness needs to include communications plans as well. We all need the capacity to inform people without inflaming them, so they don’t panic. On this issue, SARS was a wake-up call. Across the world, only 8,000 people got sick, but it paralyzed the Chinese and Canadian economies for several weeks and caused several billion dollars worth of economic disruption.
Posted June 10th, 2007 at 1:18 amIn fairness to the HHS, United States is not the only country engaged in misinformation of the public about the risks of a possible pandemic. That is why we see mixed messages from many countries. The die was cast on October 25, 2005 in Ottawa, Canada where world leaders concluded a conference on pandemic preparation and readiness, resulting in the Ottawa Communique.
The net result since then was a coordinated effort by member nations and the WHO to obfuscate and confuse the public about the risks of a pandemic. The thinking was that the cure was worse than the disease. If the public is kept in the dark, there will not be immediate panic (as was seen in SARS) in order to buy time to find a solution. Unfortunately, this collective behavior is not dissimilar to a cancer patient avoiding early treatment in the hope that at a later date a easier miracle cure will be found. The only problem is the longer you put off taking the painful medicine, the bigger the dose needed if it works at all.
This conference took place before there was enough time to really understand what happened during the SARS outbreak, and it was not until December 2006 when the truth about SARS was really known.
Now that the world knows, leaders must act responsibly and correct the course.
The 2005 Health Ministers Conference - Look who’s there.
www.hc-sc.gc.ca/ahc-…
The Ottawa Communique
www.hc-sc.gc.ca/ahc-…
5. In addition to animal-human health collaboration, Ministers identified three other key policy areas for immediate attention to ensure that the prevention, planning and response to a potential pandemic influenza are carried out in a fully collaborative manner among all countries and multilateral institutions:
(a) strengthening the capacity for surveillance, early detection and diagnosis of, timely communication about, and rapid response to a range of infectious diseases;
(b) developing a global approach to vaccine and antiviral policy for research, development, increased production capacity, access and distribution; and
(c) coordinating risk communications.
13. Ministers recognized that coordinating risk communication activities among countries and multilateral institutions is essential to inform the public, avoid panic, and prevent economic and social disruption.
Posted June 10th, 2007 at 2:45 am“I am sure that what any of us do, we will be criticized either for doing too much or for doing too little…. If an
epidemic does not occur, we will be glad. If it does, then I hope we can say… that we have done everything and made every preparation possible to do the best job within the limits of available scientific knowledge and administrative procedure.”
—US Surgeon General Leroy Burney,
Posted June 10th, 2007 at 5:19 pmMeeting of the Association of State
and Territorial Health Officers, August 28, 1957 (1)
Greg:
Excellent points.
Where the consequences of inaction are sufficiently severe, action to reduce risk should not await either scientific certainty or political popularity.
The WHO Working Group reported in September 2006 that H5N1 could achieve pandemic form without significantly reducing its mortality.
Influenza research at the
human and animal interface
www.who.int/csr/reso…
We should not assume that mortality will remain the same, but can we assume it will drop to no higher than 7/10s of 1%? (The current government “Severe 1918-like” assumption used for planning purposes. www.pandemicflu.gov/…)
If we are planning for what ‘could’ happen, not just what ‘probably will’ happen, we need to take that WHO Working Group Report into account.
That does not necessarily mean that such a high mortality rate will be the average. But few experience the average in any pandemic.
Globally, 1918 had an average case fatality rate of around 2.5%. In the US the average CFR was closer to 7/10ths of 1%.
Certain areas in 1918 experienced Case Fatality Rates well into the double digits. It is reasonably foreseeable that certain areas in the next pandemic may as well.
So if we are planning for CFRs that are reasonably foreseeable we should incorporate the potential that local communities may not all fall in the middle.
Some will be lower.
But others will be higher.
We should plan accordingly.
Posted June 11th, 2007 at 2:16 amGreg,
Thanks for highlighting an excellent point: in the absence of definitive answers, how much should we as societies invest in preparing for ‘hypothetical’ risk? After all, there are too many horrible things that can befall us as a civilization, including a giant meteor hitting the planet!
To me, the hurricane analogy is still perhaps the most useful model. On any given day, we face a hypothetical risk of a direct hit by a hurricane on the town that you live in. We can estimate our risk from how many hurricanes happen per year and how often they hit a particular area. The answer for most people is that the risk is very low indeed.
On the other hand, if a hurricane has already formed over the Gulf of Mexico, and it is picking up speed and strength and headed your way, most of us would start paying attention, if only to check the weather warnings more frequently.
If this is more than your normal run-of-the-mill hurricane, if you’ve been told that a Category 5 hurricane is headed in your general direction and may hit in the next 48 hours, wouldn’t it be prudent to assume the worst and make preparations?
Of course, the hurricane can still weaken, as they often do, after they hit land and before arriving in your area. Or it may become deflected and hit some other area instead. But you don’t know that, and waiting around to find out may mean that it’s too late to save yourself, as tragically many found in New Orleans.
With regards to H5N1, we are, at the current time, at exactly the same position as New Orleans 24 hours before Katrina hit.
We have made some preparations. A lot of people have evacuated, but many haven’t. The vast majority, including officials and experts and engineers, believed that the levees would hold and provide some protection. If they worried about it, they probably believed that they could bring in reinforcements to co-ordinate rescue attempts. They probably did not count on communications to be severely disrupted so that co-ordination was next to impossible for the initial 48 hours!
What they didn’t realize, of course, is that a disaster of the scale of Katrina or H5N1 tests all the weakest points of a system all at the same time. Since rescue or recovery depends on multiple resources being functional, disasters beyond a certain scale, be it a Category 4 or 5 hurricane or a pandemic caused by an H5N1 virus, require many extra layers of redundancy or slack in preparation just to maintain minimal functions.
The problem is, the scale of what is needed to build in any slack is so enormous that it is impossible to fund it completely out of the public purse. Plus the deployment of such resources in itself would consume another huge portion of the meager resources available.
What is to be done then?
The answer, IMHO, lies in building up distributed stockpiles of resources. Resources that are so local that, come a pandemic, we won’t have the additional burden of distribution consuming our very limited and precious ability to rescue those in need.
And when I say distributed, I mean it both in the geographical sense and in the sense of burden of funding.
If every household and every citizen are adequately and clearly informed of a possibly imminent pandemic by H5N1, just as they would need to be informed of a possibly imminent direct hit by Katrina, then they can be educated about steps that they can take to build up their personal resilience. Preparations at the level of individual households, funded by the citizens themselves, at a time when the economy is stable and most people can afford to build some slack into their resources, albeit gradually, would distribute both the resources and the burden of funding in such a way as to make the resources most accessible in a pandemic, as well as make them most affordable for society as a whole.
The government’s most important role is to inform accurately, and advise appropriately.
The building up of personal resilience at the household level does not require huge amounts of funding from the public purse. Granted there will be some who cannot afford even the minimal level of 2 weeks of stockpiles, and may need some outside assistance. But the point is, would it be better to not have the 95% prepare in fear that the 5% cannot have the same level of protection? Or would it be better to assume that those 95% who are prepared will be better able to care for those 5% who are not?
Posted June 11th, 2007 at 7:19 amDr Dworkin,
Two thumbs way up. Very good.
BTW, once again I heard on the discovery channel of people learning from the past. “The city of Seattle is taking a Tsunami seriously as we know it has happened in the past.”
Now if cities could only take a pandemic seriously - and learn from the past.
Thanks again. Glad to see SusnC post again.
Regards,
Kobie
P.S. Thanks for clearing up the error message:
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You are posting comments too quickly. Slow down.
Posted June 11th, 2007 at 8:37 amDr Dworkin,
Something just occured to me - pre-emptive strike.
While peparing others and helping them come up to speed - do not wait for it to come to us. Let us go to it first!
Let us train on H5N1 while it is over there. Then we can help our allies in Eroupe.
Train? Find out what works. Help support those doctors with the experiance protect their intellectual property while distributing good news and practices to us.
Do we have a public real time H5N1 incident maps like China does? Hmm, might need to make one.
Just a thought.
Regards,
Posted June 11th, 2007 at 11:46 amKobie
Kobie,
Posted June 11th, 2007 at 2:15 pmI have been thinking about that as well. We need real-time combat experience. That would be preemptive. I would be willing to go to Asia or Middle East. Learning over there could be teaching over here.
Richard Mitchell (Post#13),
Wow. Few people would jump into the jaws of the unknown.
I thank you for your post. I agree with you and support the idea.
On Admiral Agwunobi blog on what to stockpile I put down medals and plaques simply because I believe in people like you that I *know* are out there. Yes Jamestown 1607 and the revolutionary war was people who left a comfortable house to fight. United Flight 93 was those who did not volunteer but rose to the occasion. I was not just being polite or trite.
BTW the metal trinkets are not in payment of service but as official recognition of service. To say “I was there and I can prove it” But then any post pandemic talk is stupid when there is so little being done to get ready for a pandemic.
I think Dr. Dworkin will agree that it would be nice to know what we need before we get started! Sometimes that can rendered beforehand.
Wonder if they are taking volunteers yet?
Regards,
Posted June 11th, 2007 at 2:57 pmKobie
I would hope HHS has plans for working with H5N1 in more than just Norway rats. I would actually feel safer providing care to a victim of the current avian H5N1 than the unknown human variant. I think the simplest way to prep for HCWs is;
Posted June 11th, 2007 at 4:02 pm1. Learn everything we can.
2. Be ready for anything.
Dr Dworkin,
You ask about precautions. There are ones that either pay for themselves or pay a dividend now.
If a country will spend billions on the Olympics or 1 trillion on a presidential race - why not spend that on the infrastructure we all use.
Dr. Dworkin we have disagreed on triage - not because it is a bad idea I just do not want to see things come to that.
Yes I am glad the NYSDOH has one. Each state should have one - but used only as a last resort - preferably a hundred years from now.
Can we not start building up the hospitals now?
The improvements will pay dividends to ER patients before the pandemic starts.
If I am wrong - please correct me.
Again - folks - how do we make this happen? SusanC, C3jmp and others have some very scary and *real* numbers.
Regards,
Posted June 12th, 2007 at 8:44 amKobie
“In advance of such an event, we must develop triage criteria that depend on clinical indicators of survivability and resource utilization to allocate scarce health care resources to those who are most likely to benefit. These criteria must be tiered, flexible, and implemented regionally, rather than institutionally, with the backing of public health agencies and relief of liability.”
From the Abstract;
Concept of Operations for Triage of
Mechanical Ventilation in an Epidemic
John L. Hick, MD, Daniel T. O’Laughlin, MD
The exercise here is to familiarize HCWs with the concept that while current “triaged” patients in our emergency care areas have to wait, triaged patients in a pandemic will probably die. There are several publications now, including the U.S. Army, War Surgery Manual that are “should” reads.
We do need to develop a mindset of getting a job done objectively. We can all have a good case of PTSD later, but after reading TGI by John Barry, this is the best way for me to prepare.
Posted June 12th, 2007 at 12:43 pmI would really like to see the experts on this forum work with the CDC to develop a set of PBS programs to educate the public. No nonsense, no panic–just a reasonable set of preps to make at home and in the community, how to quarantine, etc.
Posted June 16th, 2007 at 9:00 amAnnie, RN, see this comment and the one above:
blog.pandemicflu.gov…
That sort of thing on PBS would be ideal.
Posted June 16th, 2007 at 9:40 amDr. Woodson’s post of..” your departments own projections state that about 80 million Americans will be treated at home with or without their physician’s assistance.” defines the HOT issue.
Think about it, even a moderate pandemic arrives and no concerted effort has been made to publicly and honestly prepare them on HOW to prepare and the NEED to prepare NOW. Ignoring the percentage of people who will die because they simply cannot get their routine but lifesaving health care, from hemodialysis to blood transfusions to medications-think of people literally trapped in their homes.
Not by rising flood water. By sick family members-the well ones-who could be young children-have no idea what to do. No one answers at the doctor’s office. The 911 operator said there are no ambulances or place to take them even if the ambulances were available.
Then what? Who wants THIS on their conscience? Will some of TPTB want to make a radio/TV address of “oh yeah, we meant to tell you this was coming but we kinda didn’t want to scare you or cause a negative effect on the economy”
As Greg says, the precautionary prinicple applies. So does just being a human that cares.
Posted June 17th, 2007 at 8:16 am