Influenza Vaccine Overrated?

Study reignites vaccine, antiviral controversy

Debate to mandate the (flu) shot or not for healthcare workers in the United States continues as additional data suggests seasonal influenza vaccine may not be all its cracked up to be.

Canadian healthcare workers are getting two differing opinions on mandated flu vaccine according to a report published by Public Health Ontario/Canadian Medical Association. Some Canadian researches continue to endorse the mandated flu vaccine policy for healthcare workers citing an 86% effectiveness when the vaccine is well matched to circulating virus. Researchers also claim that flu vaccination of healthcare workers in long-term care facilities (LTCF) may decrease resident flu mortality by 5-20%. The Canadian report, published in CIDRAP, the Public Health Ontario editorial indicates that flu strains that may produce Guillian-Barre Syndrome (GBS) are avoided in vaccine production. Its not clear how, exactly, GBS causing strains of influenza are kept out of vaccine production.

In the United States many healthcare systems and some sates are mandating participation in a flu vaccination program, according to the Centers for Disease Control and Prevention (CDC). “Participation” may include mandated vaccine, vaccine or singing a declination form, or mandated to don a mask.

Adding to the vaccine mandate controversy is a report from the Center for Infectious Disease Research and Policy at the University of Minnesota. This report proposes that seasonal influenza vaccine offers little protection to otherwise healthy young and middle-age individuals. They also believe that the benefit may be even less for those greater than 65 years of age. The New York Times recently printed an editorial on this topic.

While the vaccine debate continues, use of the antiviral drug Tamiflu is drawing concern. You may recall that Tamiflu (oseltamivir), and a class of medications known as Neuraminidase (NA) inhibitors, has been used to treat influenza. These medications are also on the CDC list for the treatment of seasonal influenza. However, reports have suggested that influenza has become (or is becoming) resistant to Tamiflu. One report from the CDC (9 Jan 09) states early data from a limited number of states indicating that a high proportion of influenza A (H1N1) viruses are resistant to the influenza antiviral medication oseltamivir (Tamiflu®). An article in Medscape highlights Tamiflu concerns brought on by researchers in the British Medical Journal. If you'd like to read in scientific detail about Tamiflu resistance, check out this post from the Virology Blog.

What’s the answer?
We have to remember that season influenza A continues to change every year. Some years the vaccine is well matched to the circulating strain, while other years it may not be. Its important to have an understanding of the terminology, types and impact of influenza (see 3 things to know about seasonal flu MJ 11/10). You should also brush up on the non-pharmaceutical interventions of hand hygiene, respiratory etiquette, and (appropriate) social distancing.

Selling the Preparedness Mindset

A recent comment got my attention; it should get yours, too. 

 

Aaron Marks posted a comment in response to No surprises in Sandy's wake that will hit home for many in emergency management as we struggle to make a successful pitch for preparedness. Although his comment specific to business and commercial preparedness, I think the spirit of the post can be applied to the public/civilian.

Aaron Marks writes:


For most of the people who follow MJ you're preaching to the choir here. The million dollar question is how do we fix it? 

I spend most of my time these days trying to convince business owners to invest in preparedness - with extremely limited success. Most of the decision-makers and so-called leaders out there just don't want to acknowledge that there is an issue because once they acknowledge it there may be liability associated with failing to do something about it. How do we convince 'the massess' that preparedness is an INVESTMENT and not a cost?

Why is preparedness such a hard topic to sell?

We should put the word sell in parenthesis. We can be selling the idea of preparedness or selling a product or service related to preparedness, or both. In there may be the problem. We’re trying to convince people in the community, business owners, public officials, or civilians that a certain action needs to be taken when most of those we’re selling to haven’t ever experienced any kind of serious event. And they don’t think they ever will. Many individuals and business owners have used phrases like “that’s what I have insurance for” when rationalizing their lack of preparedness.

What we’re “selling” is the preparedness mindset.

Persuading anyone to buy or do something they don’t think they need is an extraordinary uphill trek. After terrorist attacks and natural disasters woke us from the slumber of complacency, we’re eager to hit the snooze alarm and get back to business as usual. Or at least back to business of the new normal...whatever that may be.

The sad and unrelenting fact is that in the face terrorism, pandemics, and devastating natural disasters, many continue to believe that “its not going to happen to me.” In June, 2008, we wrote about this in the posting In search of preparedness in America. That post generated considerable discussion. As I wrote then “governments seem to have lacked the stamina to keep up with preparedness...” and I continue to believe that today. The response to and recovery from Hurricane Sandy continue to make my point here in 2012. You’d think that with Sandy fresh in our minds that preparedness would sell itself.

The liability of acknowledgment.

We also described an interesting, yet disturbing trend in October, 2010 (see Cassandra Paradox)  - We’ll call it the Theory of Successful Blame.

“Emergency planners, managers, and responders are responsible for actions taken (or not) before, during, and after disaster situations. While emergency planners, managers and responder should be held accountable for their performance during crisis or the performance of their planning or training preparedness, it seems that the need to have a scapegoat overpowers the reality that many of the disaster situations are fluid and may not evolve as predicted. Unreasonable expectations need to hold someone accountable when an unpredictable situation goes astray.”

The point is that acknowledged or not, someone is going to be held accountable. The preparedness liability exists and will remain on someones shoulders. A review of of the Hurricane Katrina/Tenent Health decision is a good reminder of this.

How do we convince the masses?

What we should be doing is informing and keeping it simple. Informing that preparedness is a cost effective in financial and life safety terms. We can provide information and rationale that may be helpful in bringing awareness to the forefront.

E. L. Quarantelli (University of Delaware Disaster Research Center) is my most cherished resource on emergency management teaching. In his paper More and Worse Disasters in the Future (1991); Quarantelli provides us with decent talking points, if not ammunition, to get people thinking about their need to embrace preparedness (click here for PDF).

For example, Quarantelli suggests that:

• Natural disasters will increasingly generate technological disasters
• Old kinds of natural disaster agents will simply have more hit and along some lines more vulnerable populations to impact
• There are technological advances that add complexity to old threats
• Many of the future threats or risks have high catastrophic potentials by way of the casualties or kinds of injuries they may generate
• Some of the future disasters while occasioning relatively few casualties or physical damage will be very economically costly or socially disruptive

Perhaps the most poignant statement in his paper is this:

Better disaster planning can mitigate the impact of these future kinds of disaster but will not prevent their occurrence.

 On a more individual note, you might consider advocating a preparedness program that focuses on the home and the family. Doing as much as possible towards making individuals and family groups will go a long way in making communities as a whole more resilient in times of crisis.

Healthcare realities you can't ignore...anymore

Healthcare facilities: part domestic preparedness and part public safety.

Simply meeting building and fire codes do not equate to resiliency and checking off the Joint Commission preparedness requirements does not mean you're prepared.

Healthcare facilities will need to function before, during and after an event. The goal is to maintain operation as independently as possible for any foreseeable threat in your hazard vulnerability assessment. Those that can’t do that will need to evacuate or move their operations to another facility. Sheltering in place or evacuation are clearly realities each facility must face. They’re big decisions. Both options require substantial pre-planning and functionality between facilities.

Sheltering in place.

Deciding to remain in your facility during an event (sheltering in place) is not an easy choice. On the surface it may appear that staying put is a simple thing to do but, sheltering in place (making the decision not to evacuate ahead of a threat) comes with its own set of risks. Hopefully you have a robust 96-hour plan that you’ve trained on and tested. Hopefully it’ll see you through the situation. Even with solid planing, we have to has how long can you remain in your facility without outside support? Of course you have memorandums of understanding (MOU) with a variety of vendors as required by the Joint Commission. So, you're set. Right? The interesting thing about MOU's is that your vendor has an MOU with  all their clients, not just you. Will they be able to deliver their goods or services when demand is maxed out by all clients? Consider that infrastructure damage, such as damage to roads and bridges, will prevent shipments from making it to your supplier and further, prevent them from making delivery to you.

Part of sheltering in place is having a series of decision points or triggers that will tell you when its time to change tactics. Trigger events are situations that cause you reconsider your current position and may indicate the need for evacuation.

If you haven’t got a functional 96-hour plan or if your plans are questionable, you may want to consider evacuation ahead of a threat if possible.

Evacuation.

Evacuation of a healthcare facility is a major event. There are risks to go along with the benefits. Before you give the order to begin the evacuation process you need to consider the following:

• Will this be a full or partial evacuation?

• What is the available capacity of receiving facilities? Can they absorb the number of patients we wish to send?

• Have the receiving facilities damaged by the current event or are they in danger of being evacuated themselves?

• What resources are available to move people and equipment?

• What are the risks of going out into the environment?

Keep in mind that surge capacity may exist before an event, but not during or after. Evacuations must be done early or pre-event whenever possible. Ideally, your evacuation plans and triggers have been shared and tested with other facilities.

Vermont EMS Conference

Vermont EMS Conference, Burlington VT

I'd like to extend a special thanks to conference attendees and organizers, especially All Clear Emergency Management, for inviting me to present at the Vermont EMS Con!

I truly enjoy public speaking and presenting at emergency service conferences and in 2012 I've been invited to conferences from Alaska to Vermont and many places in between. Speaking at conferences and meeting other emergency management and EMS professionals always excites me. I often return home energized from meeting proactive people and with a head full of new ideas.  The sessions on Special Needs in Crisis and School Bus Rescue were very well attended with a considerable amount of audience participation. Just the way I like it.

Travel to the Vermont conference had an added, albeit challenging, twist...hurricane Sandy. When I left home in the afternoon of October 28 predictions for Sandy's landfall were being confirmed. I figured I'd bump into this category 1 storm at some point.

On the NYS Thruway Eastbound

It wasn't long before I was driving along side convoys of utility trucks with license plates from the Great Lakes area to the Gulf Coast.

The road conditions pictured at left are actually from a local weather system and not from Sandy...I'd meet up with her later.

Welcome to VT

The approach to Vermont. Leaving New York and entering Vermont is punctuated by crossing Lake Champlain via this massive bridge.

Note that, while overcast, the weather is nothing less than cooperative at this point. From here its another hour into Burlington. A six-hour drive from Rochester, NY.

Sums up my feeling toward air travel in general

After getting checked in and settled I took a recon walk to check out the conference area and rooms.

Along the way I found a pumpkin carving display in the hotel lobby. The carvings had a obvious EMS theme.

The Scare Care pumpkin...precisely summarizes my feelings on air travel.

A bit less inventive but obligatory Star of Life pumpkin.

As I said, an EMS theme. When I checked back the next morning there was something missing.

Take note of the topic listed just below mine. I was impressed with the number of emergency management/preparedness topics at this conference. Rory Putnam is the EMS Clinical coordinator at Northern Essex Community College. He hit a home run with his talk on EMS preparedness. Rory and I had a few minutes to talk during lunch. I appreciated his insights on EMS and disaster situations and hope to have him on Mitigation Journal podcast soon.

No laptop for me.  This was the second conference I worked entirely from my iPad and controlled with the iPhone. I use Keynote (Mac version of PPT) on my iPad and Keynote Remote for iPhone. Connected via Bluetooth I can see current slide, preview next slide and view speaker notes on the phone.

The iPad/iPhone-Keynote setup is simple to use and user-friendly at the podium or walking around the room. 

The Special Needs topics have been growing in popularity. This session focused on preparedness, including a how-to on conducting a hazard vulnerability assessment.

As with all my presentations, I customized the content with Vermont-specific statistics to add relevance to the message. 

A not-so-ominous to the South approaching the Vermont/NY state line at 5pm October 29, 2012. 

Welcome to NY...just ahead of Sandy. I did feel a sense of accomplishment knowing I'd filled my gas tank in Vermont and paid a buck-fifty less per gallon than I would in NY.

This is also the point in the trip when the weather started to change. My drive through the Southeastern Adirondacks was a zig-zag of downed trees and wind-driven rain. It was also darker than I've ever known it to be. No pictures...but made it home safe.

Thanks, again to the organizers of the VT EMS Con. I had a wonderful, albeit short, visit. See you next year.

Evacuation: Should I Stay or Should I Go?

Not an easy decision but its not a trick question

When to order an evacuation is no easy decision. It never has been. Its also not a trick question and you have plenty of time to study for the test.

Controversy surrounding evacuation of civilian populations and healthcare facilities has bubbled for many years without clear resolution. And for good reason - there is no "one size fits all" approach to the problem.

The hard taught lessons from Katrina, Joplin, and Tokyo showed up on another disaster test. The final grade isn't in, but its not looking good. In the aftermath of hurricane Sandy, as the public and public health struggle to regain a foot hold on normalcy, we're wondering why problems of power, evacuation, sheltering, and fuel are persisting.

Here's a review of evacuation considerations from Mitigation Journal edition #41 - Should I Stay or Should I Go? Points to consider when deciding to shelter in place or Evacuate - overviews issues for individuals, families, and healthcare facilities to consider when making this critical decision.

MJ Podcast #41published October, 2007*
 

*Note: original audio from 2007 and has not been edited. It may contain outdated material.

Decontamination at health care facilities