Attention: Battlefield mentality required to get through the upcoming influenza season

(CIDRAP Business Source Osterholm Briefing) – I bet most of you never thought that your workplace would demand the tools of the military battlefield, including the concept of anticipated casualties, to prepare for an inevitable microbial attack. Well, I'm convinced you will.

Yes, we are breathing a temporary sigh of relief with news that the occurrence of new cases of novel H1N1 infection in the northern hemisphere countries is slowing. We might be tempted to take a break from our pandemic preparedness efforts, even with fall just weeks away, but we must resist that reasonable temptation.

Converging information points to a troubling outlook for the upcoming influenza season in North America, Europe, and Asia. In my last column I detailed the likely impact that novel H1N1 flu will have on our healthcare system this fall and winter even if the virus doesn't mutate or reassort into a more virulent influenza strain. The picture hasn't improved in the past weeks.

So what can you expect to happen in your organization this fall and what should you be doing now to prepare?

To be blunt: Start thinking like a battlefield commander. Such a mindset will best serve you and your organization right now and in the difficult months to come.

What we're learning now

Each day brings new information that can help focus our efforts.

  • Winter in the southern hemisphere. As we watch what's happening in the current winter influenza season in the southern hemisphere, we learn more about what we can expect for our upcoming flu season in terms of case numbers, disease severity, and the impact on society.
  • Vaccine. We are seeing the anticipated "unexpected" developments with H1N1 vaccine production that will determine when and where supplies become available—and who will be fortunate enough to be protected against the next wave of the pandemic before it occurs.
  • Antivirals and respiratory protection. Global supply chain and government stockpile information tells us a lot about who will have access to protective tools like antiviral drugs and respiratory protection devices.
  • Off-site issues. Many businesses are realizing that fulfilling the traditional occupational health and safety requirements for their employees while at the work site does nothing to guarantee that they won't get infected in their non-work hours. In the end, ensuring that your employees don't get H1N1 influenza is not about work site liability but about having a sufficient workforce to carry out the critical functions of your organization.

So why do I believe that we need to take a page out of the battlefield commander's playbook to most successfully navigate the fall/winter wave of the novel H1N1 influenza?

When the military is planning for any battlefield encounter, it undertakes an intelligence preparation of the battlefield, often known as IPB. With this approach, the military in a sense games that future encounter and attempts to imagine and account for all battlefield eventualities. In the case of H1N1 infection, I believe we've got four critical factors that will determine the impact of H1N1 on our battlefield. They are:

  1. Availability of a protective vaccine
  2. Availability of antiviral drugs for prophylaxis (in contrast to their use for treatment)
  3. Availability and use of N-95 respiratory protection devices
  4. How well employees take steps to protect themselves during their non-work hours

Let me detail what you might—or even should—expect with these four critical factors.

Pandemic vaccine

Expect the unexpected. In the past 2 weeks, we've seen the first and second attempts to produce vaccine virus from the seed stock. The yield is below what was expected. And we're just now beginning studies to determine what the appropriate dose will be. The hope is that in October, we'll know how much antigen each shot will contain, how many shots we can actually get from our vaccine production, and who's going to get vaccine.

But here's the caveat: It's entirely plausible that if the flu season occurs early or production problems occur, we'll have only limited amounts of vaccine, certainly not enough to vaccinate 300 million citizens. Unfortunately, millions of those who will be affected by the shortfall are healthy workers between the ages of 20 and 40. This is a gaping black hole.

Our next steps depend on how much of and when the vaccine is available. We must also take into account that little vaccine will be available in China and India, countries where many of our critical products are produced and where we can expect to see high levels of worker-related illness.


Our government stockpiles are primarily intended for treatment. Antiviral medications are not stockpiled for prophylaxis of the general population. Remember that prophylaxis is the use of antiviral drugs on a daily basis to prevent infection from occurring. It's good we have them to treat people, but we aren't going to prevent everyone from getting sick. When they're sick, they're sick. And that means you're going to lose workers for periods of at least 7 days.

N-95 respirators

In an upcoming column, I'll review a growing body of data that indicates aerosol transmission plays a bigger role than once believed. The use of surgical masks will play only a limited role in protecting your workers. If you're really trying to achieve no or limited transmission of the virus but you've got workers in an environment with infected people, you've got to have N-95 respirator protection around the clock as long as individuals are in contact with each other. In contrast to old wives' tales about flu being spread via droplets and fomites, you're going to see a growing body of information that implicates aerosol transmission.

The problem is that bulk supplies of N-95 respirators can no longer be found. The supply chains are inadequate to order even minimal numbers. You need to expect that you won't have them.

Off-site issues

Last but not least, you need to consider how workers are going to protect themselves during off-work hours. It's one thing to protect them at work, from a liability point of view. But if you need those workers at work, you need to be certain they don't get infected when they're off premises. You can encourage them as much as possible to follow protective measures, but you have no guarantees they'll follow through.

Here's where the military mindset comes in

If all the factors I've described above collide during this upcoming influenza season, there are going to be a hell of a lot of sick people in the age-group that makes up a large part of your workforce in the northern hemisphere. So what's your course of action going to be?

You have to expect a high level of anticipated casualties. The military always tries to protect its own. They also know and understand that, inevitably, there are going to be casualties. And they account for such a possibility in their planning. They plan to promote from within. If they lose three lieutenants, they know three sergeants who can be promoted. They also anticipate the number of troops that will be needed to win a battle.

Bottom line for your organization

You need to plan for redundancy of three to four levels if widespread illness occurs for weeks to months. What will you do if you don't have managers or workers to do the tasks that must be done? Answer those questions and you'll be building a critical action plan. Don't let another precious second go by.


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