February 9, 2006

Issue

It is the position of the American Ambulance Association (AAA) that all ambulance service providers have access to the necessary funding and resources to be prepared and plan for the possibility of a Pandemic flu outbreak. As America ‘s first response and safety net, ambulance services across the country must be included in federal, state and local government efforts to plan and prepare for what may be widespread infection involving H5N1 Influenza. The AAA will further act as a clearinghouse for information to ambulance service providers on preparing and planning for a Pandemic Flu.

The following outline provides ambulance service providers across the country with the first steps in preparedness and awareness of the issue. While not intended to be a comprehensive pre-plan, this document provides the basic guidance and suggested references to assist providers in their preparations. Special thanks and recognition is given to the members of the Professional Standards Committee who worked so diligently to provide their professional input and expertise for this document.

AAA Position & Background

Public health officials have recognized pandemic Flu as a significant public health threat for several years; it is just now coming to the attention of politicians, media, and the public. The Professional Standards committee of the American Ambulance Association will update the EMS community on current issues and assist in proactive planning for a highly contagious respiratory pathogen pandemic, be it avian flu or other contagion.

Pandemics are common to the history of man, causing and ending wars, affecting the intellectual growth of societies, and causing some of the very first efforts at public health. Pandemic plague was the reason that Venetian authorities invented quarantine in the 1460s. This quarantine required incoming ships to remain idle for 40 days. The seamen were not allowed to disembark, load or unload cargo during that time. Spanish Flu in 1918 is now considered as much a cause to the end of World War I as was military strategy.

In epidemiology, an epidemic is defined as a disease that appears as new cases in a given population, during a given period, at a rate that substantially exceeds what is expected, based on recent experience. Defining an epidemic can be subjective, depending in part on what is “expected.” An epidemic may be restricted to one locale (an outbreak), more general (an epidemic) or even global, (a pandemic). Common diseases that occur at a constant but relatively high rate in the population are said to be endemic.

Pandemics are dramatic events with profound consequences for which communities must prepare. The last significant influenza pandemic in the United States occurred in 1968 when approximately 34,000 people died. Why then all of the concern with the current H5N1 avian influenza outbreak? This subtype of avian influenza has the potential to act like the great Spanish Flu pandemic of 1918 when 550,000 deaths were attributed to the flu in a single season. Philadelphia alone recorded 11,000 deaths over an eight (8) week period.

H5N1 Influenza

Avian Influenza is common with at least 144 known subtypes of which H5N1 is one. What seems to set H5N1 apart has been its profound pathogenicity, or its ability to cause extreme illness in birds and ease of transmission to other birds. The first appearance was thought to have occurred in wild birds with mutation and dissemination to domestic bird stocks through out Asia and now part of the Middle East . Of particular concern is the apparent re-infection of wild migratory bird flocks with subsequent spread among the continents being likely. Other animal hosts infected include swine and cats.

With wide spread disease occurring in birds, the likelihood of human contact increases and consequently the likelihood of human infection. For an influenza virus to become a pandemic flu pathogen, three things must occur; it must infect humans whose immune systems are naive to the virus; it must be virulent or cause illness; and it must be able to spread from human to human. H5N1 has shown itself to have accomplished the first two requirements. It has infected humans, it is virulent, and may only be one or two mutations away from spreading from human to human.

Like other influenza viruses, H5N1 infects humans through the respiratory tract. We must breathe it in, or from contaminated hands, introduce the virus to the respiratory mucosa via the eye, nose, or mouth. The symptoms of the disease include rapid onset of severe illness signaled by a fever spike greater than 101 degrees Fahrenheit with subsequent respiratory symptoms and respiratory distress. GI symptoms of vomiting and diarrhea have been reported. The World Health Organization (WHO) tracks each reported case of human H5N1 disease. As of January 23, 2006 WHO reports 151 cases with 82 deaths.

Pandemic Planning

Much of the current planning and preparedness activities surrounding EMS involves an “all-hazard” approach to mass casualty incidents, hazardous materials spills, tornadoes, multiple vehicle crashes, weapons of mass destruction and many other natural and man made disasters. These events are rarely ongoing, and are generally geographically contained. A cornerstone of this planning has been the ability to call on EMS resources from neighboring areas to bolster the needed response. Unlike other mass casualty incidents, pandemic planning requires community plans to be self-sufficient. In essence, when the whole world is sick, there is no one to call for additional help. It is of course, just this problem that makes pandemic planning difficult.

Luckily EMS has a few models and lessons to refer to in preparation for a pandemic. Most pandemics are caused by respiratory pathogens. We can therefore look at past preparations and rules relating to our past experience with SARS and tuberculosis as our starting points. Mass relief efforts and shelter operations such as those associated with past natural disasters provide a reference point for planning quarantine, isolation, and contingency health care facilities.

It is beyond the scope of this article to describe the community planning needs for a pandemic. However, the Centers for Disease Control and U.S. Department of Health have published a guide to community planning available at http://pandemicflu.gov/plan/statelocalchecklist.html to assist the EMS community and other first responders in this endeavor. Suffice it to say that ambulance services and EMS agencies must be engaged at the local level planning meetings. It is suggested that every ambulance service administrator be familiar with the contents of the Centers for Disease Control and U.S. Department of Health community planning guide.

Specific modeling tools to help EMS agencies grasp potential patient numbers are available at http://pandemicflu.gov/plan/tools.html. Of particular interest is Flu Surge, a modeling tool that predicts hospitalization and fatality rates.

Business level planning is critical for all EMS and first responder agencies. A good starting point is the planning guide and checklist from the Centers for Disease Control available at http://www.cdc.gov/flu/pandemic/checklists.htm. It is estimated that up to 40% of EMS staff and First responders will be stricken with the disease and unavailable to work for an unknown period of time. Contingency staffing plans must be anticipated and readily available prior to any need. With this basic tenet in mind the following issues must be considered:

1. Can dispatch protocols be modified to provide specific healthcare instructions to callers that may have the flu and not need an ambulance? During an outbreak of respiratory disease, patients that should be treated without transport, and those that truly need ambulance transportation must be identified early in the dispatch process. Identifying the “worried-well” must also be included early in the dispatch process. This is the first step in reducing the spread of disease and maximizing appropriate use of community resources.
2. Is there an effective infection control policy and procedure for the service? Do all employees know what and where this policy is? Is there an equipment and vehicle decontamination procedure in place? The use of appropriate personal protective equipment is paramount during an outbreak of respiratory disease, much less a pandemic. Minimally, each employee involved in patient care must have a N95 mask, gloves, eye protection, and isolation gown for each point of contact. Planning for supply stockpiles and re-supply must be considered in the plan. Are those supplies easily available and accessible to crews? Special consideration should be given to supply loss as a result of spoilage, and theft. Count on some supplies to suddenly turn up missing. Consider how many pairs of gloves an agency buys compared to the number of patient transports per year and you can easily understand the point.
3. What, if any, emergency expanded scope of practice rules exist for your area. EMS agencies could, and probably will, be called on to help in mass immunization programs or mass distribution of medications. Are your personnel capable of these tasks and are they permitted to perform these tasks? Under which circumstances? What legal authority exists to assist your agency in carrying out these duties?
4. Have employees been informed of the need for personal and family preparation? Are your employees able and willing to potentially come to work for days on end and not see family, either due to workload or the need to remain isolated to prevent the spread of disease from work force to family?
5. What are the personnel policies regarding illness obtained at work and the continuation of a paycheck due to being in isolation or quarantine? What does your Workers Compensation plan say about the issue?
6. Is there a local quarantine and isolation authority? How does it work? Will your agency be involved in the staffing of such a facility either by demand or contract? The same questions may also apply to contingency health care facilities and must be considered.
7. Do you have an established working relationship with your local public health department or authority? They will likely be the agency calling the shots during a pandemic. Planning, practicing and becoming familiar with these individuals now will help your agencies response and operational effectiveness when a pandemic occur in the future.
8. It is imperative that planning continue and not be set aside simply because there is no current “crisis” to deal with. Failure to plan now will most likely have significant consequences should a pandemic event begin to materialize.

Personal and family preparation for any disruptive health event is highly suggested and strongly encouraged. Information about personal disaster and pandemic preparedness is available from the Centers for Disease Control and Department of Homeland Security as well as non-governmental agencies such as the Red Cross.

Board Action: Approved by AAA Board on: February 9, 2006