Preparing for pandemic

Gearing up for H1N1

Region planners take steps to ready health-care system

BY JOEL SCHLESINGER
Winnipeg Health Region
Wave, Fall 2009

It's a daunting task.

Figure out a way to give influenza shots to as many as 500,000 people. Twice. When it comes to preventing the spread of the H1N1 influenza virus this fall and winter, the job of organizing mass immunization clinics is one of the more challenging ones.

It's easy to see why. Not only do you have to identify venues large enough to vaccinate hundreds or even thousands of people at a time, you also have to make sure they are properly staffed and accessible. What about parking? What about security? Is it on a major bus route?

Then there is the little issue of having to explain to people that the vaccine may be administered in two doses to ensure effectiveness, although recent reports suggest one dose may be enough. And, of course, the H1N1 vaccine should not be confused with the vaccine for the seasonal influenza. That is an entirely different vaccine, one that will be administered weeks before the H1N1 vaccine is available. That means, when all is said and done, health officials expect they will have administered more than one million doses of vaccine this season. And that is unprecedented.

The H1N1 immunization program is just one example of how the Winnipeg Health Region is preparing for a possible resurgence of H1N1 influenza this fall and winter. Ever since the virus surfaced in Manitoba last spring, hundreds of people working on dozens of committees have been tackling issues ranging from how best to immunize the public to staffing for Intensive Care Units with two goals in mind: to prevent the spread of the virus and ensure those who become ill get the best treatment possible. Now, with the flu season just around the corner, all those hours of deliberation and planning are being put into action. The plan is about to be tested.

Dr. Sande Harlos is the Medical Officer of Health for the Winnipeg Health Region and one of the key players in the H1N1 readiness effort. Although the planning process has been in high gear for several months, Harlos says preparations for a possible influenza pandemic began many years ago.

"One of the reasons we were able to respond as well as we did to the H1N1 surge last spring was because we had plans in place," says Harlos. "But with the work that has gone on over the last few months, I am confident that we are in an even better position to respond to whatever unfolds this fall and winter," she says. "I can't say enough about Region leaders and staff members and the work they have done. But it doesn't stop there. Our people have been working with outside groups - the City of Winnipeg, the province, physicians, school divisions, business leaders, volunteer agencies and other community groups to try and make sure all the bases are covered. It's typical of Winnipeg - everyone just pulls together to get things done."

Much of the broader thinking about pandemic preparedness involves high-level planning among governments around the world, leaving organizations like the Winnipeg Health Region to focus on implementing prevention and treatment issues. As a result, the Region's team of planners has put every facet of health care under the microscope to prepare for a possible resurgence of H1N1.

The H1N1 plan is based on several scenarios that take into account demands on the system. "The first goal is prevention. We've tried to look at all the things we can do as a Region to help stop the spread. In some cases, that means looking at immunization clinics or ways to prevent patients who may have H1N1 symptoms from coming into contact with others who may not. In other cases, that means ramping up our communications efforts to ensure people living in our community know how to reduce their risk or where to go if they need care," says Harlos. The second goal is treatment. "We have made every effort to shore up our supplies and bring in additional staff, should the need arise. The planning has been very detailed," says Harlos.

Trish Bergal, Director of Utilization for the Winnipeg Health Region, is responsible for co-ordinating the activities of many of the groups that have been working on the H1N1 readiness project. She says the springtime H1N1 surge provided a good test of the Region's existing plans, and highlighted some areas for improvement. "You can always anticipate in your head what you might want to do if it (a pandemic) happens. But when you begin to see patients affected by H1N1, then your plan is actually being tested. That's where the real-life experience comes into play," she says.

One of the key areas of the plan involves supplies. Peggy Maitland, Director of Logistics Services for the Region, says hospitals had enough respirators, gloves, gowns and other protective gear during the first wave of H1N1. But the experience did provide some insight into how to better equip hospitals in a larger emergency.

As a result, the basic necessities have been addressed for the fall: purchase orders for masks, syringes, hand sanitizer and other supplies have been placed, and large orders for the N95 respirator masks have arrived. During the spring and summer, the Region consumed what would have been a two-year supply of N95 respirators. Should the H1N1 threat fail to materialize, the four million N95 respirators ordered would amount to a 20-year supply under normal conditions. The Region has also acquired about 20 new ventilators, a potential trouble spot identified before the outbreak occurred, Maitland says.

In addition to acquiring basic supplies, the Region's planning team is also taking steps to ensure it has enough Tamiflu and Relenza, antivirals that are helpful in treating viruses.

Of course, one of the most important questions centres on hospital capacity - how many patients can be placed in critical care beds in the worst-case scenario.

It is estimated that five to 10 per cent of Manitoba's population of about 1.2 million people has been infected by the H1N1 virus. But some experts have suggested a pandemic virus could infect up to about 65 per cent of the population in a worst-case scenario, with some of those affected requiring care.

Betty Lou Rock is Director of the Region's Critical Care Program and has been overseeing efforts to ready Intensive Care Units throughout the city. She explains that the Region would normally have about 69 critical care beds available for use. During the springtime surge, the number of beds needed jumped to 75 to accommodate about 70 additional patients infected with the H1N1 virus, an increase that required significant redeployment of staff. Going forward, the Region has developed a multi-tiered plan to add critical care beds and staff as the need arises. In the worst-case scenario, the Region would be able to staff 130 critical care beds, or more than double the normal number.

Given that the Region is not going to be able to hire healthcare providers en masse in the midst of a crisis, a comprehensive plan for redeploying existing staff to work the additional critical care beds is crucial.

Kim Smith, a senior project manager on the H1N1 readiness team, says part of the planning process entailed looking at what types of procedures could be postponed, and for how long, in the event of an emergency redeployment. "You know you can't stop women from having babies, so that is going to continue to happen," says Smith. "But there are areas where you can postpone elective surgery for a short period of time" and redeploy the staff, if needed.

Part of the planning involved going through a process of identifying the skill set of all staff working within the Region. With more than 28,000 people working within the Winnipeg Health Region, there are cases where someone working in administration, for example, could be redeployed to the front lines in the event of an emergency. The Region may also bring back some retired health-care providers on a temporary basis, should the need arise.

Ensuring health-care workers are healthy enough to provide care to those who are sick is another important element of the planning process. As a result, the Region has taken a number of steps to ensure staff are properly supported through access to health services, or simply making sure there are places within hospitals and clinics where they can eat and rest.

One of the big issues, of course, is how to make vaccine for H1N1 available to the public once it is ready for use. While Health Canada and Manitoba Health are responsible for ensuring there are enough doses to go around, the logistics of immunizing residents in Winnipeg and East and West St. Paul falls on the shoulders of the Region.

As a result, the Region is ramping up its seasonal influenza immunization program with a view to applying lessons learned to the H1N1 campaign.

Normally, the seasonal vaccine is made available at various clinics and doctors' offices throughout the city over a period of about six weeks. You can still get your shot at your doctor's office, but this year instead of the usual clinics, the Region is planning to stage 12 large clinics throughout the city to dispense immunizations over a three-day period, beginning Oct. 14. Each clinic will be open between 9 a.m. and 9 p.m. and have three shifts of about 20 health-care workers administering the vaccine. The Region hopes to be able to administer about 24,000 doses during the three-day period. Through this effort, the Region will be able to determine how many people it can efficiently immunize over a short period of time. The mass vaccination effort will be helpful as the Region prepares to implement the H1N1 immunization program, which is expected to begin in late November.

An important aspect of the work being done for the H1N1 effort involves surveillance and epidemiology. As Harlos explains, "We need to investigate and learn as much as we can about an outbreak so we can invest that information in even better planning. That takes a cast of hundreds whose hard work is usually pretty invisible to the public." In the case of influenza, for example, a sample from an individual may come into a lab for testing. Once staff confirm that it is a case of influenza, a public health nurse will visit the individual in question and interview him or her, as well as other friends or family members, to gather more medical information.

Through the interview, the nurse can learn whether the individual may have some underlying condition, such as asthma or diabetes, or whether the person smokes or has a higher BMI (overweight) than average - all factors that could help shed light on why the person became sick.

Next, staff enter the information into a database created by epidemiologists who use the information to conduct analysis. By creating these indepth profiles, public health practitioners get a better understanding of who may be most at risk should a second wave come about.

Based in part on the data collected, not just in Winnipeg, but across the country, health officials have identified a list of groups who appear to be at higher risk for becoming sick. They include people with chronic medical conditions under the age of 65; pregnant women; children six months to under five years of age; people living in remote and isolated settings or communities; health-care workers involved in pandemic response or who deliver essential health services; and household contacts and caregivers of individuals who are at high risk, and who cannot be immunized (such as infants under six months of age or people with weakened immune systems).

For those who develop flu symptoms, the Region has also planned processes and capacity for treating and caring for large numbers of people.

A committee co-chaired by Dan Skwarchuk, Executive Director of Health Services Integration, and Dr. Michael Routledge, Medical Officer of Health, developed a multi-tiered plan for handling different scenarios of potentially large volumes of patients developing influenza symptoms.

The plan, developed with participation from public health, child health, obstetrics, primary care and family medicine, community health services, acute and ambulatory care, calls for awareness and education strategies for patients to self-assess their degree of illness and to determine if health-care provider assessment is required. People who need help with their self-assessment may also call Health Links - Info Santé for assistance, and, if necessary, visit their health-care provider for examination.

Should the number of H1N1 cases increase this fall, Region Primary Care Clinics and ACCESS Centres are also exploring the possibility of altering hours of operation and reprioritizing services to see more patients with influenza symptoms. In addition, the Region is working collaboratively with family physicians throughout Winnipeg to help ensure their work is adequately supported in the event of an outbreak.

Should there be a dramatic increase in H1N1 activity within the city, the final stage of the plan calls for the establishment of two special influenza clinics - one at Health Sciences Centre, and one at Seven Oaks General Hospital. Potential for additional clinics in other locations is also being explored. These clinics would help assess and treat flu patients while also offering access to antiviral medicines where needed. But those with more serious symptoms (such as shortness of breath or severe weakness) would still need to seek higher levels of care, such as the kind available at hospital Emergency Departments.

The Region is reaching out in other ways. First Nations, Métis and Inuit patients coming to the Region from other areas have the benefit of accessing services such as interpretation of medical terminology, physician instructions and health-care related information in Swampy Cree, Ojibway/ Saulteaux, and Oji-Cree/ Island Lake dialects. Assistance with discharge planning is available in complex situations, as is support and advocacy during hospitalization and some clinic visits. These services are accessed by referral through Aboriginal Health Programs - Health Services central intake line at 940-8880.

Harlos says the planning that has been done should help ensure any surge in H1N1 activity is handled as effectively as possible. But even if the threat is less than planned for, the community-wide measures put in place today and the mass immunization clinics in the near future lay the foundation for better pandemic planning for the long-term.

It's a threat that will likely never disappear, Harlos says, because influenza is ever-present, perpetually mutating in the background - as if the hand of fate is constantly pulling on the slot machine of nature, waiting for the right conditions to line up and result in a pandemic.

"And if influenza viruses mix and match in a way that results in a virus different enough that people have no immunity, and if it can spread effectively from one person to another, then it could be the virus that starts the next pandemic," she says. "That's the kind of beast influenza is."

Joel Schlesinger is a Winnipeg writer.

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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