By Bill Peckham
This afternoon the World Health Organization raised the pandemic alert level to 6, the highest alert level. Dr Margaret Chan Director-General of the World Health Organization (WHO) made the announcement:
On the basis of available evidence, and these
expert assessments of the evidence, the scientific criteria for an
influenza pandemic have been met.
I have therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6.
The world is now at the start of the 2009 influenza pandemic.
The 2009 influenza pandemic. I thought we would see a level 6 pandemic announced a month ago, so this announcement shouldn't be a surprise. Chan's announcement does reveal a change in how the WHO perceives H1N1's severity:
Globally, we have good reason to believe that this
pandemic, at least in its early days, will be of moderate severity. As
we know from experience, severity can vary, depending on many factors,
from one country to another.
On
present evidence, the overwhelming majority of patients experience mild
symptoms and make a rapid and full recovery, often in the absence of
any form of medical treatment.
Previously the H1N1 virus was described as having a mild severity (there were many reports equating the severity of illness caused by H1N1 to the severity of illness caused by seasonal flu). This change to moderate was, I think, precipitated by H1N1's apparent severity in Canada's far north among the indigenous population - Canada's First Nations.
If the H1N1 virus causes moderate disease generally it appears to be causing severe disease in those with underlying health conditions, conditions that include CKD5. Over half of the deaths from H1N1 have been in people with underlying health conditions, while it is thought that about one third of the overall population would be said to have an underlying health condition.
We don't know the true severity of H1N1; we don't know what the practical difference is between mild and moderate influenza strain by the WHO's reckoning. The one piece of data that Chan provided in her announcement was:
In some of these
countries, around 2% of cases have developed severe illness, often with
very rapid progression to life-threatening pneumonia.
It is hard to have any confidence in Chan's 2% number. In order to calculate the virus's severity, e.g. What percent of those who get sick need hospitalization? And of those, what percent die?, we need to know the number of people infected. Right now we only have guesses since testing for the H1N1 virus has largely stopped. We also would have to calculate severity based on the number of people infected when those hospitalized or dead were first infected. If the disease takes several weeks to manifest its severity then calculating the attack rate or fatality rate by using current prevalence will understate the severity.
Mild, Moderate or Severe - What Should We Do right Now?
I think these four months before the start of our seasonal flu season is God given time that the US renal community should use to prepare for a significant influenza event. Preparation should focus on established emergency preparation best practices. For individuals this includes a two weeks stockpile of food and prescription medications, preparation for if someone in the household gets sick: over the counter medications, and basic medical supplies e.g thermometer, blood pressure device, and non-pharmaceutical interventions e.g. masks, hand sanitizer.
Dialysis units should follow emergency planning best practices:
• build infrastructure and strengthen relationships with local emergency planning officers
• planned flexibility; prepare for worst-case scenarios
• engage patients, staff and MDs in planning
• communicate plans to stakeholders and public
Every dialysis unit should have a working relationship with their local emergency planning department - in Seattle this is at the county level, in other jurisdictions it could well be someone else. Dialysis providers must consider bad scenarios. The course of the current H1N1 pandemic is very similar to the course of the 1918 H1N1 pandemic, frighteningly similar. Both started with the flu season extending into summer but with what was seen as a mild severity. There are a number of questions dialysis providers must answer now as part of their preparation.
Units need to consider what they will do if 50% of their staff does not report to work for a prolonged period; units need to establish policies if a staff person has flu symptoms; if a patient has flu symptoms; what to do if members of patient or staff households exhibit flu symptoms. These policies must be based on the assumption that local hospitals will be overwhelmed. Dialysis unit policies and procedures cannot rely on emergency medicine to treat patients that have the flu or exhibit flu symptoms.
Emergency planning best practices direct planners to include their stakeholders in the planning process - for dialysis providers this would include patients, doctors, staff and patient families - because building and maintaining trust is a vital component to successful emergency planning. By including all stakeholders in the emergency planning process and then communicating the plan before it is needed, dialysis providers can increase the trust that will be necessary to maintain the provision of dialysis.
Patients need to know that dialysis will not be withheld if they exhibit flu like symptoms. The provision of dialysis is going to face a severe challenge; we have four months to prepare. Let's use the time wisely.
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