DISCUSSION: Prioritization in the Health Care and Community Support Services (HC/CSS) Group

COMMENT THREAD

• Health Care personnel exposure, why vaccinate those who've recovered?
  

  Submitted by Brant Goode   on 12/5/07 07:18 AM

  Good Morning Caroline,
  
  Your concern that many Health Care Personnel would be exposed through work is why this group is in Tier 1, but you raise an interesting point about why bother vaccinating persons who've recovered. Prophylactic treatment with antivirals prior to vaccination may indeed offer protection, and PPE should also help, but neither of these are ideal solutions. PPE is not as easy to maintain for hours on end, much less days or weeks. And antivirals may not be available in sufficient supply for weeks of preventive treatment. Preventive treatment also does not necessarily lead to ongoing protection once the treatment stops. The idea that vaccine should be reserved for persons not yet infected is good to note--some health care personnel may well become infected, adequately treated and recover-thus without needing a vaccine.
  
  You might propose adding a category for not receiving vaccine: those who have recovered.
  
  Brant

  • doesn't make sense to use antivirals for weeks as preventative
    

    Submitted by Caroline Bridgers on 12/5/07 07:38 AM

    Shouldn't antivirals just be used as treatment?
    
    If there is a plan to identify those health care workers who come down with pandemic flu, they can be treated, most will according to stated planning assumptions, recover, and then these Health care workers will no longer need to be included in priority for the scarce vaccine when it become available 6 months later.
    
    I'm sure this has been modelled.
    
    Someone here must have a planning estimate of what percentage of HCW are expected to come down with pandemic flu. If we are anticipating and making planning decisions based on an estimated 30% of the general population will come down with pandemic flu -- then is there an estimate of how many health care workers will come down with it? Is it the same as 30% or are people expecting more will be exposed due to their occupation (and PPE maybe running out?)
    
    Anyhow, what ever the planning assumption is for health care worker exposure, sadly, the assumption is about 2% would not recover. But the remaining 98% we are assuming WILL recover,. So whatever that number ends up being, can be removed from vaccine priority 6 months later.
    That should free up some scarce vaccine for other important groups.
    

    • great comments
      

      Submitted by Terry Adirim   on 12/5/07 08:03 AM

      I agree with you. But consider this, how will we know if a HCW has pandemic flu or some of the other viruses causing illnesses? Will we need to either test when the HCW is ill or check for antibodies prior to vaccinating?
      
      And household prophylaxis of ill persons is being considered.

      • I thought there was a test
        

        Submitted by Caroline Bridgers on 12/5/07 08:44 AM

        I have learned now that there are no tests, so I agree that this idea will be impractical.
        
        (-;

      • disagree with prophylaxis use of Tami
        

        Submitted by Roy Kamen on 12/5/07 09:09 AM

        prophylaxis with tami on that scale is undoable and dangerous to making the virus resistant.
        
        Each family member should have a seasonal vax. Then if they get sick they take double dose of Tami for 10 days... so each household should have a stockpile of Tami to take immediately upon getting sick - which if there was a severe flu going around and they get the flu.

        • use of antivirals for H5N1
          

          Submitted by eric kelley on 12/5/07 10:37 AM

          It is my understanding that at this time we have no antivirals which have been effective with any of the patients and or family members who were exposed to or who had H5N1. Is this correct?
          Eric

          • Tamiflu used successfully in Indonesia and Egypt.
            

            Submitted by Roy Kamen on 12/5/07 10:40 AM

            It has been used successfully. They use double doses for twice as long and when given early in the illness, people survive.
            
            Some believe that their tests then show Negative to the virus, are declared Negatives, then sent home.

            • Will The Tamiflu Blankets hold?
              

              Submitted by Roy Kamen on 12/5/07 10:44 AM

              This is the million dollar question...
              
              Will The Tamiflu Blankets they are using as a containment strategy keep working in Indonesia?
              
              And if not, how much time do we really have?

            • Will The Tamiflu Blankets hold?
              

              Submitted by Roy Kamen on 12/5/07 11:15 AM

              This is the million dollar question...
              
              Will The Tamiflu Blankets they are using as a containment strategy keep working in Indonesia?
              
              And if not, how much time do we really have?

            • sorry double post.
              

              Submitted by Roy Kamen on 12/5/07 11:16 AM

              sorry double post.

            • Tamiflu use
              

              Submitted by eric kelley on 12/5/07 01:23 PM

              Roy, thanks for the update.
              Eric Kelley
              

  • OSHA can't figure this out for for personal protective equipment
    

    Submitted by Nick Kelley on 12/5/07 09:02 AM

    OSHA has been very clear in regard to PPE (personal protective equipment) that there is not enough available evidence to make regulatory recommendations about what PPE recovered workers would use. As of now everyone needs to have PPE if they are at risk of being infected with influenza, regardless of their recovered status.
    
    There are many regulatory loopholes that would have to be jumped through if recovered workers were not vaccinated.
    

    • Interesting conversation - but is it On-track?
      

      Submitted by Nicholas Dewar   on 12/5/07 10:09 AM

      Nick (and others)
      You've raised an interesting topic on this thread, and it's clear that you and the others here are very well informed about this. However, PPE etc. is not the real purpose of today's discussion. Can you please help us consider the prioritization for Health Care and Community Support Services (HC&CSS) that is proposed in the Guidance? It's really important for us to hear what you think of this, especially because you appear to have thought about this a lot.
      Thanks for your help with this.

      • Hard to seperate
        

        Submitted by Nick Kelley on 12/5/07 11:22 AM

        I think we are starting to drift in the topic, but its becoming clear that the guidance being offered in place of vaccines or until vaccines arrives is causing concern among many of us. Maybe there is a need for the other guidances to be addressed in another forum. Its just difficult to separate the topics as all the other topics that have been discussed are needed to work well, as this guidance depends on them.
        

  • Verifying immunity to virus
    

    Submitted by Sharon Hutchins on 12/5/07 10:16 AM

    I really like the idea put forth by Caroline and Brant that we might skip vaccinating those (no matter what tier) who have been infected with and recovered from the virus. My concern is how we will document this. Will we take blood from and run tests on all critical infrastructure personnel in the tiers before offering vaccination? This is likely to take a lot of time, effort, and lab resources. If we don't test to be sure, some people who think they got the virus and refuse vaccination, but got a different illness would then not be protected. I'm not sure how likely this scenario is, but I imagine some would worry about it.

    • A high attack rate/ case fatality rate scenario
      

      Submitted by Catherine Jackie Mitchell on 12/5/07 10:25 AM

      A high attack rate/case fatality rate scenario causes me to lean towards placing health care and community support services in a higher tier and keeping infrastructure stability and support as the main priority. With many people succumbing the fear factor may just keep too many people from working in their communities.

      • high priority for infrastructure
        

        Submitted by Roy Kamen on 12/5/07 10:38 AM

        Agreed.
        
        BUt keep in mind it may be the armed services and National Guard who end up doing the heavy lifting.

        • but also
          

          Submitted by Catherine Jackie Mitchell on 12/5/07 11:02 AM

          Public perception, once again, may be crucial to compliance. If there is a perception that we are being over militarized, no matter how the military is benefiting the general population, there may be other issues that need to be considered. A balanced response from all sectors would prevent this from the outset.
          
          Military also has other duties that are and will be crucial.
          

          • Agreed
            

            Submitted by Roy Kamen on 12/5/07 11:17 AM

            Agreed

        • NG cannot keep the lights on
          

          Submitted by larry wright on 12/5/07 01:30 PM

          the training and knowledge base requirements are too extensive.

• Healthcare and vaccination
  

  Submitted by Joel Palmer on 12/5/07 07:24 AM

  I wish I could remember where the discussion took place, but recently I was party to a talk about this very issue. We were debating how far into the pandemic healthcare workers would be before most if not all had been exposed to the bug.
  
  I do know that many plans call for placing recovered individuals in the most exposure-heavy positions, given that the illness/recovery will serve the same role as vaccination in prepping their immune system to fight off further illness.

  • Healthcare and vaccination
    

    Submitted by Victoria Davey   on 12/5/07 07:38 AM

    Joel,
    I think the problem is with assuming that healthcare workers who've gone through a pandemic wave protected by PPE and perhaps antiviral drugs have adequate immunity. PPE and antiviral drugs protect from infection. No infection--no immunity. Certainly if we had high sensitivity diagnostic tests to determine definitively who had been infected with the pandemic virus, one could be fairly sure of immunity and comfortable putting unvaccinated healthcare staff on the front lines. But absent those good diagnostics, or good epidemiologic evidence that illness and recovery confer protection, healthcare workers could so easily remain very vulnerable for subsequent waves, and thus warrant being vaccinated. Vaccination of healthcare workers would protect them from illness and from transmitting infection--both very important to managing/containing a pandemic.
    
    Victoria Davey
    

    • Won't we have tests to determine who has been infected?
      

      Submitted by Caroline Bridgers on 12/5/07 07:59 AM

      Victoria-
      
      Help me to understand what you are saying.
      
      You said:
      
      "Certainly if we had high sensitivity diagnostic tests to determine definitively who had been infected with the pandemic virus, one could be fairly sure of immunity and comfortable putting unvaccinated healthcare staff on the front lines."
      
      Do we not have these tests? I thought they had been or are rapidly being developed.
      
      also
      
      "But absent those good diagnostics, or good epidemiologic evidence that illness and recovery confer protection,..."
      
      Again, I do not understand. I assumed like with regular flu, illness from pandemic flu would confer protection against that strain. If this will not be the case, how do we know the VACCINE will confer protection?
      
      also you said:
      
      "Vaccination of healthcare workers would protect them from illness and from transmitting infection--both very important to managing/containing a pandemic."
      
      But then, how can we manage and contain a pandemic, BEFORE we have the vaccine? If we figure out strategies for the first 6 months, can't we just continue to use them?
      
      Everyone is saying how important it will be for certain groups to help us maintain functioning during a pandemic, so they NEED PRIORITY for a vaccine. OK, but now I'm getting worried... if they really need it, how on earth will they manage without it?
      
      I appreciate you taking the time to help me work through this.
      

      • Won't we have tests to determine who is infected?
        

        Submitted by Victoria Davey   on 12/5/07 08:27 AM

        Caroline,
        
        I'll go through your questions one by one:
        
        Do we not have these tests? Well, remember that we don't have a pandemic strain now. We have H5N1--the influenza strain that is causing a pandemic in birds, but we no human pandemic influenza virus circulating now. There are diagnostic tests that distinguish major types of flu (A vs B for example) from one another and even some that help diagnose H5N1, but the tests are not perfect, and tests to use rapidly to distinguish a pandemic strain of flu would have to be developed when we had more knowledge of the actual pandemic strain. There is much work going on to develop good rapid diagnostic tests for regular (seasonal) flu and pandemic flu.
        
        I assumed pandemic flu would confer protection?
        
        Yes, if a person has a case of pandemic flu, that person would likely be immune. But we were talking about healthcare workers and whether to vaccinate them after the first wave of a pandemic--individuals who would be intensively exposed to pandemic in subsequent waves. If we weren't sure they had been infected (say they had had only a mild illness that might have been a common cold), I would not feel comfortable in declaring them immune and not in need of vaccine for a second wave unless I had some evidence from a diagnostic test proving they had had the pandemic flu.
        
        How will we know vaccine will confer protection?
        
        Vaccines go through a strict battery of tests in the lab and in people to prove their effectiveness before they are approved for use.
        
        How can we manage and contain a pandemic, BEFORE we have the vaccine? If we figure out strategies for the first 6 months, can't we just continue to use them?
        
        We can use what are called community mitigation strategies (see pandemicflu.gov for the entire guidance document). Community mitigation strategies are measures to contain a pandemic by reducing contacts between people (that lead to transmission) coupled with using antiviral drugs that also can help diminish transmission. Community measures would be applied according to pandemic severity. Let's take the case of a bad pandemic--like 1918. Our community mitigation measures would include: having sick people stay home, dismissing schools, asking children and teenagers not to congregate together, closing public gatherings (parades, church, sporting events), asking families or household members of persons sick with influenza to stay home and away from others until the sick person is recovered and treating the sick person with antivirals as well as giving the household members antivirals to prevent their getting sick and transmitting. Sick people and family members around them would wear facemasks. If people had to go out in crowds, they would wear facemasks. Everyone would be advised to wash their hands frequently and cover their mouths and noses when coughing. It is thought that these measures, if done by a high percentage of community members, could go a long, long way to limiting a pandemic. Certainly, we would continue to use these measures throughout the pandemic, and even after vaccine began to be available, depending on how everything was working together (community mitigation, antivirals, vaccine).
        
        Great questions!
        
        thanks
        
        Victoria Davey
        

      • Tests to document immunity from infection or vaccine
        

        Submitted by Brant Goode   on 12/5/07 08:33 AM

        This is a great discussion thread. We don't yet have tests approved for an event that hasn't yet occurred--they'll be developed rapidly but the demand for testing will almost certainly outstrip capacity--sound familiar?
        
        Nonetheless, identifying those who are protected either from infection or vaccination will not likely occur as quickly or easily as it might. The use of antivirals is currently focusing on treatment vs prevention, although increased stocks will allow some targeted preventive treatment.
        
        We can predict--with degrees of uncertainty--that a vaccine may have similar efficacy as seasonal flu vaccine. That said, we will have to measure such efficacy during the actual event.
        
        Finally, re the need to slow the pandemic before we have a vaccine that does work: this is where non-pharmacologic interventions (NPIs) have deep value.
        

        • Don't assume the infected cannot be reinfected
          

          Submitted by Katharine Fisher on 12/6/07 07:14 AM

          I would assume that most of the audience here today has read Barry's book, The Great Influenza. In it, you might recall the story of one unfortunate doctor who was infected three times during three separate waves. He survived.
          
          Today we have a pre-pandemic vax (albeit in very limited quantities). It may offer "some" protection, according to Dr. Webster. His hope, if my recollection is correct, is that it would not necessarily protect from infection, but that those infected might contract a milder case than they ordinarily would (i.e. they'd become sick, but would not die). That vax is based on a very old strain, Vietnam circa 2004 (maybe it's time to call in the Antiques Roadshow guys).
          
          When a pandemic strain emerges, we will create a vax using that strain. That vax will not be available even to our President until around 6 months later, and everybody else on the allocation chart we are currently at work here will be vaxed after that, in the order determined. This means that many people will not be vaccinated until 9 months to a year (realistically) have passed. Because influenza strains mutate constantly, by the time most of the general public gets vaccinated, what they are really getting might be equivalent to another pre-pandemic vax. In other words, a vax not current with the by-then-circulating strain.
          
          In fact, we may be chasing the tail of viral mutations for quite a while. Unless we can quickly ramp up a DNA vaccine capability (or some other modern technique) that is nearly immediately responsive, we will almost certaily never catch up with the potential reassortments and recombinations that can (and likely will) occur with *the* pandemic strain. In fact, we may see the emergence of several pandemic strains, perhaps simultaneoulsy, from the multiple clades (and too many to count) sub-clades now circulating. Any of these individual clades could recombine, or they may reassort independently with seasonal strains.
          
          Most planning asssumptions state that seasonal flu vaccine production facilities will be given over to pandemic vaccine production, either severly limiting or ending our supply of seasonal vax. However, seasonal influenza will still circulate, and without vaccine protection reassortments with the pandemic strain will be possible. Additional circulating pandemic strains can be created in this way.
          
          Matching vax to a constantly changing pandemic strain target is going to be a difficult undertaking. This season, we have been caught short because our seasonal flu vaccine does not contain protection against the newly emerged Brisbane strain that recently came out of Australia's flu season, and which has already hit our shores. The Brisbane strain is a simple variant of the usual Wisconsin H3N2 that has been included in this years trivalent seasonal vax, but even that small mutation away from the norm made by the new variant leaves us unprotected during this year's flu season as far as the Brisbane strain goes. (I know, you are all *hoping* that some small bit of protection will still be provided, but that's just a hope at this point). I can't imagine that finding *a* vaccine for a pandemic strain will be much easier.
          
          Each 6 month to a year "waiting period" that you are proposing for vaccine development will feel like the movie Ground Hog Day as the virus mutates and subsequent waves of variants hit.
          
          If we are to have true Homeland Security, someone needs to step up and let the public know that we need to gather our resources and do the hard and costly work of research and expansion of manufacturing capabilities that will allow us to get ahead of the pandemic strains. If we don't, we may end up chasing the tail of pandemic strains, seeing multiple reinfections of our population, and stressing our public, our economy, and our security beyond all measure.
          
          And frankly, I don't want to be the one to tell any health care worker who's survived infection that they are likely to be infected again in subsequent waves by variants that neither their prior infection nor the current vax will protect them from. I also don't want to be in the position of being a patient who is counting on them showing up for work once they are told that such reinfections are possible.
          
          Again, the truth about the complexity of this subject needs to be told to the Americna people. We will not be able to maintain our security if this is not done. More is needed than just an education program about handwashing and avoiding crowds. As a citizen, I expect those of on this panel, and your colleagues who hold similar positions, to do this hard work.
          

  • HCWs acquiring and treated for influenza during pandemic.
    

    Submitted by Mona Wenger on 12/5/07 09:03 AM

    How soon would HCWs be back to work after acquiring and being treated. Would this particular population be able to return and would they even want to return?

    • H5N1 patients recovering
      

      Submitted by Cindy Deutsch on 12/5/07 01:42 PM

      Right now only 20% of H5N1 patients recover and they aren't back to work in a week or two. They are very ill and take a very long time to recover.
      
      The virus is more than a respiratory illness. It attacks other organs as well. So there can be damage to the liver, brain, kidney, heart, and intestines as well as the placenta in pregnant women.
      

      • The virus is more than a respiratory illness
        

        Submitted by Roy Kamen on 12/5/07 02:11 PM

        That is a very good point Cindy.

  • recovered individuals in the most exposure-heavy positions
    

    Submitted by Antanina Perricone on 12/6/07 10:34 AM

    Joel:
    
    I have read prelim plans made by the City of Philadelphia that have MUAs/MAs (Mutual Agreements) between several hospitals in which recovering staff would be sent to one hospital designated to take care of sick and recovering patients while "well" healtcare workers work in one hospital designated for non-pandemic patients.
    
    I also think many are underestimating how many healthcare workers will fall ill and be unable to work as well as those who will "abandon ship" and not work at all.
    
    So in this type of scenario we are talking about a small dedicated group who might be stuck at hospitals for weeks caring for patients. These workers need vaccines and antivirals or you would inevitably create a perfect breening ground for the novel strain to mutate and change.
    

• not only health care workers, but first responders
  

  Submitted by Tanya Silva on 12/5/07 07:59 AM

  If the scenario presented was that the person already presented symptoms the vaccine will not the answer the medication in this case would be a better solution. Furthermore, your point not only should be for health care professional but for any person that has being exposed presenting symptoms. Nevertheless, the vaccines will play a vital role as in any case it will ameliorate any symptoms presenting if the virus kept changing and other subtype would attack.

  • Vaccination of HCW's and First Responders
    

    Submitted by Karen Rose on 12/5/07 08:08 AM

    From what I understand about the influenza virus, it rapidly mutates. By the time second and third waves of the pandemic flu hit, the virus may be different enough that those with exposure and immunity from the first wave are now unprotected from the second or third wave. Vaccination of these front line folks should remain a high priority, even if they developed immunity to the first wave, in my opinion. Does the science back me up here or not?

    • mutation and subsequent waves
      

      Submitted by Catherine Jackie Mitchell on 12/5/07 08:12 AM

      From what I recall though exposure/recovery during a first wave would still allow some protection from a mutated virus. Please correct me if I am misspeaking.

      • not necessarily
        

        Submitted by Roy Kamen on 12/5/07 09:15 AM

        not necessarily. In 1918 1st wave infection didnt always protect against 2nd wave.
        
        It will depend on how far the Virus sequence moves between waves.
        
        better to have lots of food at home.

        • yes but would the CFR drop
          

          Submitted by Catherine Jackie Mitchell on 12/5/07 09:21 AM

          With subsequent waves I would think that someone could become ill but in theory would the case fatality rate drop? (CFR - apart from the systemic exhaustion that illness with subsequent waves would do to someone)
          
          Then again this line of thought just involves too many variables making this line of inquiry not worth pursuing.
          

          • Worth pursuing
            

            Submitted by Karen Rose on 12/5/07 10:14 AM

            In my opinion, even though we cannot answer the question at this time, the question is valid and should be factored into plans for vaccination and anti-virals (and of course, always PPE). If Health Care workers/First responders are infected and recover from the first wave, we cannot assume they will be protected from subsequent waves. We will need science and observation to help with policy regarding vaccination for these people, rather than removing them from the list of vaccine recipients.

          • CFR in subsequent waves
            

            Submitted by Cindy Deutsch on 12/5/07 01:29 PM

            The CFR would not necessarily decrease in subsequent waves. Sometimes the second wave is much more virulent.
            

        • Will first vaccine work against subsequent waves?
          

          Submitted by Sharon Hutchins on 12/5/07 10:22 AM

          If we're talking about a scenario in which infection in the first wave does not confer immunity to the mutated virus which will cause subsequent waves, I think we also will have to worry that the vaccine (derived from the original strain 3-6 months earlier at least) will also no longer provide protection against the newer strain(s). So, we may then need to go through the vaccine development process all over again, playing catch up with the virus. Let's all hope that the virus does not mutate this much this quickly, or I think we're left with non-pharmaceutical (or at least non-vaccine) options.

          • non-vaccine options
            

            Submitted by Allison Merrick on 12/5/07 10:40 AM

            sharon -
            what might those non-pharmaceutical or non-vaccine options be?
            (quarantining?) what else?
            - allison
            

            • non-vaccine containment
              

              Submitted by Sharon Hutchins on 12/5/07 10:49 AM

              Allison-
              
              I was referring simply to PPE (personal protective equipment) for healthcare workers and distancing measures for other workers. Sorry, no new brilliant ideas in this area!
              

          • Will first vaccine work against subsequent waves?
            

            Submitted by Glenda Ford-Lee on 12/6/07 06:41 AM

            Sharon,
            
            This is my Biggest Fear. The virus mutates and then we have to have another vaccine to deliver. The possiblity is something that I have asked in many meetings with medical pesonnel of all ranks. (Microbiologist, Acute Disease, ect..)

      • Re: mutation and subsequent waves
        

        Submitted by Karen Rose on 12/5/07 09:24 AM

        I think it would depend on how drastic the mutation. We would quickly see the effects of a mutated version of this pandemic strain if those with supposed immunity began to succumb. Flexibility will be key in all of our responses.

        • How does this immunity affect the prioritization proposed in the Guidance?
          

          Submitted by Nicholas Dewar   on 12/5/07 10:13 AM

          Karen (and others in this thread)
          I'm trying to bring you back to today's focus. You're raising interesting points here. But please consider how the issue that you're discussing affects the prioritization that is proposed in the Guidance. Does it have an affect? What changes do you think should be made to the Guidance?
          Thanks for your help with this.

          • Back to the thread
            

            Submitted by Karen Rose on 12/5/07 10:17 AM

            Thanks for your comment. I think this is part of the thread, in that my point, as I stated in my last comment, is that we cannot make assumptions that the infected HCW's will not need vaccine just because they made it through the first wave. I would not want to see them/us removed from the first tier of vaccination unless we KNEW that they/we were actually immune. Hope that explains why I am hanging onto this thread.

          • No one has mentioned Non-Clinical hospital staff yet
            

            Submitted by Susan Webb on 12/5/07 12:01 PM

            In another discussion, pharmacists were referenced. How about hospital clergy, or social workers, or facilities personnel (engineers) that manage HVAC/infrastructure? Will vaccine be limited to the bedside caregiver only?
            
            Sue Webb
            EM Plan writer / healthcare system

            • So which tier would you put them in?
              

              Submitted by Nicholas Dewar   on 12/5/07 12:31 PM

              Susan (and others in this thread)
              I think that the non-clinical hosp. staff are probably included in Tier 3 of Health Care and Community Support Services. If so, do you think they should be moved higher than that level?

              • Include a small percentage of Non-Clinical hospital workers in Tier 1
                

                Submitted by Susan Webb on 12/5/07 12:43 PM

                I also understood that Non-Clinical hospital workers might fit into Tier 3. What concerns me is that it takes a multi-disciplinary team to run a hospital. I would suggest that each hospital identify 3-5 individuals from critical support departments (Pharmacy, Diagnostic Imaging, Plant Ops/Facilities, IT, Dietary) be vaccinated along with their clinical (bed side) counterparts. Maybe alot additional doses based upon licensed bed capacity: 500 beds get 50 additional doses to keep the building running.
                

            • Front Line Workers
              

              Submitted by Glenda Ford-Lee on 12/6/07 06:38 AM

              Not only All medical/healthcare workers (housekeeping, security, food workers, social workers etc) but the emergency workers that drive the vehicles. (first reponders). ( fire men and women, police men and women, etc ) They will be exposed to the virus because of the contact with the general population that will be sick.
              

          • How does this immunity affect the prioritization proposed in the
            

            Submitted by Glenda Ford-Lee on 12/6/07 06:44 AM

            I think the healthcare workers should be in the security level of the category of target vaccination. They should be considered as security for the general population along with the national guard and essential support personnel.
            They are Essential Support for our Nation.

      • How long is someone protected from subsequent infections with mutated strains?
        

        Submitted by Brant Goode   on 12/5/07 10:38 AM

        What I've heard is that there is some relative protection, but it is not absolute. Flu is a tough bug, but having natural infection with one year's seasonal flu does appear to offer some protection against related strains, but not against those not related.
        
        When a new or pandemic strain emerges, some drift mutations will of course occur, and there may indeed be some protection against subsequent strains. How much? I wish we could say.
        
        Brant

    • protection against mutated strains--need to revax front line workers?
      

      Submitted by Brant Goode   on 12/5/07 10:20 AM

      That flu viruses mutate is well-recognized, and with seasonal flu we have occasional years where the vaccine and circulating strains match less optimally. Once a novel virus emerges it will mutate as well and we may see some diminished efficacy depending on the extent of these mutations.
      
      The science will be a work in progress--many busy virology labs during the event to see how well-matched the circulating strains are to the vaccine strain(s). Note the plural here--combining more than one strain is also the standard approach with seasonal flu. Vaccine development may include use of adjuvants to enhance vaccine effectiveness.
      
      I think your proposal to maintain the priority of front line health care workers who may or may not be immune is interesting.
      
      Brant

    • can we predict whether vaccine would be effective in 2nd and subsequent waves of a pandemic?
      

      Submitted by Victoria Davey   on 12/5/07 10:26 AM

      Karen,
      
      As you point out, influenza virus is very mutable. It is thought, though, that exposure and immunity (via vaccine or through infection/illness) to a first wave virus strain should confer some level of protection to subsequent waves.
      
      Victoria Davey

• What if anti-virals are not provided or not effective to treat strain?
  

  Submitted by Debra Mattas on 12/5/07 08:13 AM

  It is my understanding that anti-virals are in short supply and will not be provided to health care workers. And even if they were---what happens if the anti-virals are not effective? With regard to the comments I've seen about excluding health care workers because it is assumed that they will be offered tamiflu or that they should have already been exposed, contracted and recovered...I don't believe that we should be taking chances with an already short supply of health care providers.

  • What if anti-virals are not provided or not effective to treat strain?
    

    Submitted by Eleanor Peters   on 12/5/07 08:30 AM

    Hi Debra - It is true that there were limited amounts of antivirals but the manufacturers have since stepped up production and there are more available now than there have been in the last few years. As to whether or not antivirals will be effective, you are absolutely right in saying that we won't know for sure. We certainly hope that they will be but we won't know until the pandemic strain emerges.

    • hedge our bets
      

      Submitted by Roy Kamen on 12/5/07 09:13 AM

      I think we should "hedge our bets" and dont expect antivirals to save your life.
      
      You may be better off with a pantry full of food to last until the stores reopen.
      

      • When the Stores Reopen
        

        Submitted by Glenda Ford-Lee on 12/6/07 06:48 AM

        
        When the stores reopen. Think about they will be down at least 40% also. Then they have to have gasoline to drive the Vehicles to get to the stores. Essential support personnel. ( I hope their names are included in that category).
        

    • Anti-virals for Volunteers
      

      Submitted by Bill Pritchard on 12/5/07 09:18 AM

      Does anyone have info on whether volunteer responders nationally, such as Medical Reserve Corps members, are being offered the same protections as health care staff in an outbreak? That's policy here in Arlington County, but I'd be curious about jurisdictions in other parts of the country.

  • I was not suggesting exclusing health care workers
    

    Submitted by Caroline Bridgers on 12/5/07 10:11 AM

    Not based on an assumption if it can't be proven.
    
    But I did think it would be frankly wasteful, to vaccinate people who have already been ill and recovered from a pandemic virus.
    
    So if there ever IS a way to test, quickly and definitively, whether someone has fallen ill from pandemic flu, then I think it would make sense to use those tests FIRST on any health care workers who want a pandemic vaccine; to be sure they haven't already been exposed. (If pandemic flu vaccine is in short supply that is.)
    
    Seems like we'll have a good 6 months at least to develop those tests, so maybe they could be used that way. Just a thought!
    

    • Can you frame comments in this thread as proposals for changes to the Guidance?
      

      Submitted by Nicholas Dewar   on 12/5/07 10:17 AM

      Caroline,
      It seems that you, and others on this thread, are developing ideas about prioritization for people who have developed immunity. Have I understood that right? If so, would you (or others) please make a suggestion of how the Guidance might be changed to reflect your concerns about this?
      Thanks for your help with this.

      • Testing before vaccination
        

        Submitted by Karen Rose on 12/5/07 10:25 AM

        If there is an effective test for the new flu strain before the vaccine is distributed, and if the test is available in adequate numbers, perhaps we could look for immunity before using vaccine for the exposed HCW's/First Responders and other Tier 1 folks. That would preserve vaccine for a greater number of people. May not be practical, but at the moment, sounds reasonable to me!

        • Thanks: that framing is helpful
          

          Submitted by Nicholas Dewar   on 12/5/07 10:31 AM

          Karen,
          thanks for framing this so clearly in terms of prioritization and the Guidance.
          

      • prioritization for those who have immunity
        

        Submitted by Caroline Bridgers on 12/5/07 01:30 PM

        OK I will try.
        
        I propose that people who have documented immunity (or maybe exposure?) to the pandemic flu virus be placed in the lowest tier for receiving the pandemic flu vaccine based on the strain that they contracted.
        
        How to document this immunity is a separate, logistical issue, but if a cheap and rapid test can be designed, and ready in 6 months, it would seem reasonable to me to use it especially with those populations who by virtue of their profession were likely to come into contact with the virus in the first place.
        
        Excluding people who already have immunity from a virus from getting a scarce vaccine seems like a very reasonable thing to do, and one even those people who were excluded could agree to, assuming they had faith in the documentation aspect. I do not know how reliable the testing is to see if someone has been exposed or if someone can be said to be immune. I do seem to recall hearing for regular flu, actually GETTING the flu brings greater protection than getting a vaccine of the same strain. Though I'm sure you health official folks here know all about that better than me, so correct me if I am wrong.

        • Excellent Idea
          

          Submitted by Catherine Jackie Mitchell on 12/6/07 05:16 AM

          Caroline, this is an excellent proposal. It is reasonable and sound to my level of logistics. I would have not idea on how to go about this but I would also urge some caution here.
          
          When we create a situation where we label and define people we set up a situation where there are some with more freedoms than others. Also if we have massive databases of names of those immune or not immune for whatever reason, we may place and extra burden on those NOT immune. Once again, peer pressure and education but also there must be some trust.
          
          I may not be doing a good job in articulating a deeper sense that I have hear on this issue. I just urge caution....
          
          just my 3c

  • health care workers treating the public
    

    Submitted by Catherine Jackie Mitchell on 12/5/07 11:14 AM

    There is an assumption here that health care workers will be the first line of treatment.
    
    There is also the consideration that with hospitals, medical clinics, ambulance services, etc. overwhelmed by an initial surge, much medical care will be undertaken in the home.
    
    Health care workers are important for treating other illnesses and injuries beyond influenza. If triage is done at the local level and care applied there as well, our health care workers may have less of a burden but that burden of care will be placed on the many volunteers who will be needed.

    • So how would you change the prioritization to handle this?
      

      Submitted by Nicholas Dewar   on 12/5/07 12:36 PM

      Catherine,
      Interesting point! So what would you (or others on this thread) suggest as modifications to the prioritization guidance?
      1. Are we talking about specific types of the "General Population" (GP) being identified as needing to be moved up to higher tiers.
      2. What types of GP members could we usefully identify
      3. any other recomendations for the prioritization?

      • General Population involved in mitigation
        

        Submitted by Catherine Jackie Mitchell on 12/5/07 02:39 PM

        I would raise the status of those in the general population who are citizen soldiers in a public health battle.
        
        There will be people who will be called away from "normal" every day functions who will serve in a capacity that is helpful to the community. Some may be "orphanage" type workers or those holding the hands of the sick and dying. There will be an extra need for cemetery workers, a crucial role to the overall mental health of the community. The list of citizen workers goes on and on. And they will come from all walks of life including but not limited to the health care field.
        

        • Community Resiliency
          

          Submitted by Catherine Jackie Mitchell on 12/5/07 02:42 PM

          Community resiliency is also extremely important for recovery between waves and after the pandemic. Community involvement is crucial. This is why I would drop health care workers down on the list. They are important but not the end all, be all, to this situation. That being said, I am not demeaning their basic value to society as a whole.
          

          • HCW's and First Responders Key to Survival
            

            Submitted by Karen Rose on 12/5/07 03:21 PM

            Community involvement will be key. Everyone will have a role to play, whether staying home to care for children whose school is closed, caring for isolated neighbors, delivering supplies, etc., etc. BUT we are talking about a healthcare/medical emergency here. Not a natural disaster. The healthcare workers and first responders are those with the training and knowledge base essential to care for the sick and provide medications and vaccines for prevention of spread of illness. They should absolutely remain in Tier 1 in ANY pan flu scenario.

• N95 protective equipment
  

  Submitted by eric kelley on 12/5/07 10:29 AM

  Referring to the N95 use during the SARES, there were several other factors.
  
  One: several of the "nurses" did not wear goggles while the patient was receiving nebulizer treatment.
  
  Second, some medical personnel did not wear eye protection in the room after the neb was done. The virus was even more wide spread in the room after the neb treatment. Even in a negative pressure room the air exchange is only 6 times per hour. There was never any testing to determine if the filtering was effective in removing the virus from the room.
  
  I hate to say it but also from having to work with isolation patients and having to go back and forth for supplies, it is to easy to become "sloppy" with the use of PPE. In addition it was thought that several of the nurses were not fit tested properly for the N95.
  
  On another note, over an 8 hr period or 12 hr, who knows how many N95's might be used by the few staff members that go into the room. And remember once the N95 becomes moist it can no longer be used. But if it does not get moist how long is it good for?? I have seen nothing by the CDC or OSHA which might suggest how long they will last in a true usage situation.
  
  I'm sorry but at this moment I can not recall the article reporting about these specifics of the medical staff with the SARES patients.
  Eric Kelley RN
  
  Eric: I edited your title for clarity. Donna/Editor
  

  • Please explain codes and Acronyms
    

    Submitted by Nicholas Dewar   on 12/5/07 10:34 AM

    Eric,
    This sounds very interesting, but is opaque to most of us. Please would you explain the codes and acronyms that you've used?

    • Explaining codes and acronyms
      

      Submitted by eric kelley on 12/5/07 01:48 PM

      Nicholas; I hope I can remember all that I used. Sorry for any confusion. And I appolize for getting off the subject.
      
      N95; the respirator/mask worn by health care workers which filters out most bacteria.
      
      Fit test; a test which is performed to determine if the N95 fits the person correctly.
      
      Isloation room; where a patient is placed in a room by him/her self. It is a regular hospital room except for the following, there is tile on the floor not carpet, the air going in and out of the room goes through special filters, there is a separet supply room attached to the room. This extra little supply room also has a entrance to the room and exit out into the main floor. The regular door which you enter the room should be locked inorder to have everyonr go through the supply room to put on PPE's.
      
      PPE; personel protective equipment; these include but are not limited to, N95, a long sleve gown which will cover your uniform, googles, possibly shoe covers, gloves.
      
      I hope I recalled everything for you.
      Eric Kelley
      

  • Effectiveness of PPE
    

    Submitted by Karen Rose on 12/5/07 12:04 PM

    Very good points. PPE must be used correctly and consistently if it is to be of any benefit. Even if used appropriately, we just don't know how effective it really might be. But, we are off the topic of vaccine prioritization. We will all be working at great personal risk when this develops, as we attempt to provide life saving care to the public we serve.

    • PPE's and being off the subject material
      

      Submitted by eric kelley on 12/5/07 01:30 PM

      Karen you are correct this is off the main topic. This also is a indicator of just how much needs to be discussed.
      Eric Kelley

  • Healthcare Workers and SARS
    

    Submitted by Glenda Ford-Lee on 12/6/07 06:30 AM

    
    The first cases of SARS was not identified as SARS cases.- After, several deaths then it was a Diagnosis of SARS. This was reported by the Nurse that managed the event for Canada.
    
    The healthcare workers will also have the first exposure to the novel flu virus. They should have the first vaccine to treat the population.

• Healthcare Workers and SARS
  

  Submitted by Glenda Ford-Lee on 12/6/07 06:06 AM

  
  The healthcare workers that contacted SARS did not know the patient that they cared for in ICU had SARS. So the nurses did not wear the N-95 during the course of routine patient treatment. If you do not give your healthcare workers, first reponders, utility workers the vaccine then we are out of luck.