We're not out of the woods yet with pandemic influenza: Is there light in this 'forest of vicissitudes'?

(CIDRAP Business Source Osterholm Briefing) – So, when's the last time you had influenza?

For me, it was Apr 23, 2009, a when day some worrisome news was emerging out of Mexico and California. I had wedged in a doctor's visit before joining a conference call with Dr. Osterholm and other CIDRAP staff to discuss the developments. I hadn't felt so sick since 1998, the last year I ever opted not to get a flu shot.

What the heck, I decided, I'm going to give my clinic a heads-up. "You might very soon start seeing a lot of patients worried about 'swine' flu," I told a nurse, physician, and lab technician. As politely as they could, each looked at me as if I were deranged. And in all fairness, my temp of 101+ gave them reason to think I might be less than reliable.

But I wasn't. Like many of you, I simply delivered information that no one wanted to hear or believe.

Do you remember that day?

What followed seems like a chapter out of the life of a medical resident. From Apr 23 forward, I remember nothing but days ending at 2 am only to start a few hours later, information and guidance pitched like fastballs from a machine on max, urgency to make sense of it all so critical decisions could be informed by reason and analysis.

To be sure, the spring of 2009 was a heady adrenaline rush, and fall only slightly more seasoned and sober. Somewhere in between I think I might have cat-napped. How about you? But now it's winter and a new year, a time to take stock.

What have we learned? What lies ahead?

To answer those questions, I turned to the best source I know—a full year of Osterholm Briefing columns written by Michael T. Osterholm, PhD, MPH, and two invited guest contributors. I've had the privilege of editing each one. But to review them as a whole was to see the forest, not just the trees. The view was uncanny; it startled me in a good way, and it gave me ample reason to believe that we are not out of the woods yet.

Dr. Osterholm encouraged me to share with you my findings; I hope they'll help inform your next steps.

Ahead of the curve

Dr. Osterholm once told me he doesn't like surprises. I assure you, he means it. So like a good chess player, he anticipates many possible moves. His skill appears effortless—the result of it appears in Osterholm Briefings. Here are just a few examples:

Jan 8: "Sure as a frigid January morning in Minnesota, another pandemic is going to occur."

H1N1 pandemic begins in the spring of 2009.

Mar 26: "One day the pandemic will arrive like an uninvited, though not unexpected, stranger on our doorsteps . . .We must not fall into a trap of thinking that we will somehow know when or where the next human pandemic strain will appear just by good luck . . . It could be 10 years from now—or it could be tomorrow."

H1N1 pandemic begins a few weeks later, not in Asia or Africa where many expected, but in the Northern Hemisphere.

Apr 16: "I would discourage disposing of them [antiviral drugs] after the expiration dates. Much can change, including a loosening of regulations when the pandemic begins . . ."

US Food and Drug Administration and Department of Health and Human Services post an alert that they are examining the use of expired antiviral drugs under an emergency use authorization.

May 1: "Perhaps the best guiding principle to keep in mind is that of proportional response. Right now, this virus is behaving like seasonal influenza. So our decisions need to be proportionate to the risk."

On Sep 23, following the first wave of the H1N1 pandemic, nearly 250 experts in business continuity, public health, and infectious diseases name flexibility and a proportional response the new gold standard in pandemic preparedness.

May 21: "Yes, it's a pandemic."

On Jun 11, the World Health Organization (WHO) officially declares a pandemic.

Jun 4: "As sure as the sun rises in the east, I guarantee you there will be more lessons to learn and very likely more challenges to your organization's plan. Consider the past 6 weeks a wake-up call. In no way can say we've dodged the bullet."

A second wave of illness when students return from summer vacation in August and September shutters numerous schools and child care centers, and the US Centers for Disease Control and Prevention (CDC) asks employers to modify sick leave and pay policies to ensure sick workers stay home.

Aug 13: "You will never hear me predict severity. Never. You deserve better. The severity of past pandemics predicts nothing about the current pandemic. Worse, it distracts our attention from what we must do right now."

While comparisons of the pandemic to a mild or moderate seasonal influenza continue in media and journal articles, an early December CDC update shows that H1N1 has caused 16 million more cases of illness than an average annual influenza season and more than 13,000 more hospitalizations.

Oct 1: "It's one thing to make vaccine that provides protection; it's another to get the vaccine into the people who need it."

No vaccine was available during the first wave. Distribution of limited amounts of vaccine during the second wave was fraught with distribution problems.

So what's the lesson? I think it's this: When you find an expert who's spot on, who gives the unvarnished facts, whose track record is as good as it gets, whose voice is clear and cogent—listen and act upon that knowledge.

Do I have 2 weeks of supplies at home? Yes. Do I stay home when I'm sick? Absolutely; I'm fortunate to have the kind of job that allows me to telework. But, more important, while I think my job is necessary, in no way is it critical enough to take chances with a wily novel influenza virus that has killed pregnant women, little children, and otherwise perfectly healthy young people. Is your job?

If you've heard it once, I've heard it 1,000 times

As an editor, one of my tasks is to eliminate repetition. I can't begin to tell you how many times I've run across the phrase "expect the unexpected" in Osterholm Briefing manuscripts—and how many times I've kept it in. Another one of my jobs as editor is to ensure clarity and accuracy. From where I sit, every mention of that term was been justified.

And that's one of the reasons why I'm not convinced we're out of the woods yet. I'm concerned about:

  1. The specter of genetic changes. Another phrase I've seen many times is the possibility that the H1N1 virus could mutate or undergo reassortment in such a way as to cause more people to become sick or sicker. If the first and second wave of illness didn't lead to unprecedented levels of absenteeism, who's to say a third wave won't?
  2. Countries are selling off unused H1N1 vaccines. As hard as the shots were to get last year, now they're in surplus? Immunity doesn't happen overnight, so if a third wave does roll around, what's that going to do to our workforce?
  3. The sick leave and pay conundrum. Because absenteeism during the first and second wave was manageable, the biggest message to employers that came from our most influential public health agency, the CDC, appears to have been met with lukewarm interest or ignored. Yes, some employers have loosened up paid time off (PTO) donation programs or allowed sick workers to take vacation leave. But as a whole, the business sector has not grappled with this issue voluntarily, even as efforts on Capitol Hill have tried to foist changes on you. Signs of trouble are evident anywhere you look. Last fall, for example, I encountered a rental car agent in her 20s who was coughing horribly and was so weak she could barely lift the paperwork. I asked if her company had told her she shouldn't come to work if she had an influenza-like illness. I mentioned that people in her age-group could get pretty sick. She had no idea. How many people had she infected that day? My 25-year-old daughter told me that her fellow retail workers flat out ignored the CDC advice because, as hourly workers, they could not afford not to work. Even if a third wave of H1N1 never rolls around, such presenteeism remains a problem, and that means the rest of us can catch what they have.
  4. H5N1. It's still out there making people sick and killing more than half of them. Given that the world has a finite number of public health resources and they've been focused on H1N1, what have we missed since spring?
  5. Healthcare services. That clinic I went to Apr 23? I was back for other reasons this fall and I asked a physician's assistant if he was planning to get the H1N1 vaccine. Nope. He'd never gotten seasonal flu vaccines before and the whole distribution mess with H1N1 just added fuel to his suspicions that "no one knows what they're doing when it comes to flu shots." I know that's an all-too-common sentiment.

So, if we're still in the woods, how do we get through them?

I'm counting on you (and myself). While attending the 2009 CIDRAP summit on H1N1 last September, I met many of you and I came away with the impression of an extraordinary cadre of people who, bar none, will do what it takes to ensure that we get to the other side of the forest, despite the uncertainties and the limits on your time and resources. So I'm willing to do whatever it takes to help you help the rest of us.

In November, we published a toolkit for human resource (HR) leaders that was filled with your tips, examples, and caveats gathered at the summit. This week we published, "Keeping the World Working During an Influenza Pandemic: Key Themes, Tips, Tools, and Checklists from the 2009 CIDRAP Summit," a follow-on to the HR toolkit. As long as I'm here and able, I'll keep collecting and giving back to you the best, most practical information and tools I can find or create. It's the very least I can do.

You're our light through the forest.

So here's my New Year's wish for you: Stay healthy, be well, and keep reading.

—Kathleen Kimball-Baker is managing editor of CIDRAP Business Source.

Note: The term "forest of vicissitudes" comes from a presentation made by a former colleague, Renie Rae Howard, who died just a few days ago.

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