Preparing Hospitals for Large-Scale Infectious Disease Emergencies

Eric Toner and Amesh A. Adalja

This article is part of Crossroads in Biosecurity: Steps to Strengthen U.S. Preparedness, published by the Center for Biosecurity September 8, 2011 to mark the 10th anniversery of the 2001 anthrax attacks. Full document | Printable PDF

                
Anyone who has been to a hospital emergency department during peak flu season has probably witnessed firsthand the strain that even a modest increase in patient volume can put on a hospital. A much larger and more prolonged surge of patients might be expected in the event of other significant infectious disease (ID) outbreaks, whether they are naturally occurring or the result of a terrorist attack with a biological agent. On the tenth anniversary of the anthrax attacks of 2001, it is appropriate to consider whether our healthcare system would be able to respond to a major ID emergency and, if not, to ask what new actions or resources are needed to prepare for large-scale epidemics.

The goal of healthcare preparedness is to save as many lives as possible by enabling a more effective medical response to a significant disaster. Over the past decade we have witnessed several notable examples of non-ID disaster response that clearly benefited from healthcare preparedness efforts— among them, the Virginia Tech mass shooting, the Minnesota bridge collapse, and the Rhode Island nightclub fire. An ID emergency, however, adds layers of complexity and uncertainty to the response, because the route of disease transmission may not be fully understood, effective vaccines and antimicrobials may or may not be available, and extensive patient isolation may be needed to prevent spread of a contagious disease.

Had the 2001 attacks involved a wide-area release of Bacillus anthracis, thousands of patients might have needed hospital care. Managing an event of this scale requires the involvement of all parts of our healthcare system, ideally working in coordination and collaboration. However, efforts to create a system in which the provision of health care can be well coordinated across a region have been hindered by cost, competition among hospitals, and a lack of government authority.1

Progress Achieved in Hospital Preparedness Since 2001

There has been notable progress. Following the terrorist attacks of 2001, the federal government created the Hospital Preparedness Program (HPP) in the Department of Health and Human Services (HHS). That program has made a significant difference in national hospital preparedness, which the Center for Biosecurity documented in 2009 when we evaluated the program.2

We found significant improvement in preparedness of individual hospitals. Perhaps more important, we found substantial improvement in collaboration among hospitals and between hospitals and government agencies (local and state). We identified these relationships as hospital coalitions, and consider their emergence to be the most significant advance in healthcare preparedness in the past decade. Their value has been demonstrated in a number of recent events—most recently, the 2009 H1N1 influenza pandemic, during which hospitals collaborated with each other and with public health departments to share information and resources.

Necessary Steps Forward

Although hospital preparedness has come a long way in the past decade, preparedness levels have plateaued in recent years. Many communities have created—or are creating—coalitions to improve resilience to common disasters, such as tornados and hurricanes, which is important. However, there is little evidence of improvement in preparedness for ID emergencies of the magnitude that would follow large-scale bioterrorism or severe pandemic flu. This is an area in need of focused attention and additional improvement, and there are several specific actions that should be taken in the near term to build national capacity to respond to large-scale ID emergencies. If achieved, the 4 goals that we set forth below would make a substantial contribution to advancing healthcare system preparedness.

Preserve, Expand Upon, and Make Best Use of HPP and NDMS

This first goal entails building and expanding upon investments we have already made, starting with the Hospital Preparedness Program. The HPP has been demonstrably effective in bolstering hospital preparedness. We cannot emphasize enough the value of healthcare coalitions in emergency response. Because the HPP can directly instigate the development and proliferation of coalitions that can, in turn, support constituent hospitals during a crisis, we strongly support continued USG support for the HPP. With continued support, this important program will be able to continue to foster the development and proliferation of the coalitions that enable healthcare entities within a community to plan, train, share information and resources, and respond as a cohesive unit in a disaster that could otherwise overwhelm.

There is another existing asset that should be maintained and expanded as well: the federal National Disaster Medical System (NDMS). It is clearly of great potential value in a national disaster. But its total deployable capabilities and capacity are limited and would be insufficient for responding to a large-scale ID emergency.

To accommodate the expected numbers of patients in an ID emergency, the healthcare surge capacity of the entire country, both public and private, may have to be tapped. Doing so would require transporting large numbers of patients to private hospitals around the country. NDMS has contracts with thousands of hospitals for this purpose, but the system depends primarily on the U.S. Air Force for long-distance transport, and the military’s capacity to move patients is quite limited and takes a long time to ramp up. Even if we had a feasible plan for moving large numbers of patients around the country, it is not clear that private hospitals would voluntarily accept large numbers of patients who were transported in for care.1,3

But this problem is solvable if the role, capabilities, and capacities of the NDMS—its deployable teams, transportation, and definitive care (hospital) components—were expanded to align with the challenges posed by anticipated threats. With input from subject matter experts and stakeholders from outside the federal government, this expansion should involve greater collaboration with and harnessing of assets in the private sector.

Improve Hospital Infection Control

During the 2009 H1N1 influenza pandemic, much debate centered on the types of infection control needed to curb the spread of the disease. For example, the relative importance of hand-washing and contact precautions were compared with the value of wearing some sort of respiratory protection. There also was considerable debate over whether respiratory protection should be a simple surgical mask or a more scarce, costly, and cumbersome N-95 respirator. The resolution of those debates depended on understanding whether influenza virus is transmitted primarily by large respiratory droplets or by fine aerosols. (This same debate occurred during the 2003 SARS epidemic.)

The available scientific data was and remains limited and inconclusive. But out of concern for the safety of healthcare workers, the Centers for Diseases Control and Prevention (CDC), following the advice of the National Academy of Sciences, recommended use of N-95 masks. However, many healthcare facilities found this to be infeasible because of cost and scarcity of masks; scarcity and shortages then led many hospitals to consider cleaning and reusing the masks. Again, due to a lack of clear scientific data, there was no guidance available on mask reuse. Complicating matters, once the CDC guidance was issued, hospitals expressed concern that they would be cited by the Occupational Safety and Health Agency (OSHA) for not following that guidance.4

This experience reinforces the need to ramp up scientific research that will elucidate the transmission characteristics of novel pathogens, inform infection control practices, and deter punitive actions against hospitals that are acting in good faith but are unable to comply with recommendations.5

Toward this end, the USG should prioritize research into the nosocomial transmission of respiratory pathogens and the efficacy of various infection control measures via the National Institutes of Health (NIH), the National Institute for Occupational Safety and Health (NIOSH), and other entities within the CDC.

Prioritize Development of Rapid Diagnostic Tests

During a large-scale ID emergency, the patients most likely to benefit from medical care and from receipt of what is sure to be limited resources must be identified rapidly. This will not be easy when there will be multitudes of people seeking medical evaluation and care. For illnesses caused by most of the biological threat agents, initial assessment based on clinical features alone can be highly inaccurate and unreliable. What is needed for effective patient triage on this scale are rapid and inexpensive diagnostic tests. To date, there are no approved rapid diagnostics for any of the major biological threat agents (ie, the pathogens that cause anthrax, smallpox, plague, tularemia, botulism, and the viral hemorrhagic fevers).

Tests to rapidly characterize unknown agents are essential to an effective ID emergency response as well. With a novel pathogen, such as the 2009 H1N1 influenza or the SARS coronavirus, the faster it is identified, the faster control measures can be implemented to stop disease spread and limit illness and death. These tests will be needed most in reference laboratories, but they may also be needed at the point-of-care (ie, in emergency departments), because transporting pathogens to labs may be difficult in some settings.5

To speed development and licensing of rapid diagnostic tests, therefore, the USG should also prioritize research on, and development and approval of, rapid and portable diagnostic tests and devices for the most serious biological agents and for characterization of novel pathogens.

Establish Capacity for Real-Time Clinical Trials and Information Sharing

Our experience with the 2001 anthrax attacks and with ID epidemics of the past 10 years—SARS, H1N1 influenza, and H5N1 (avian) influenza in humans—made clear the need for immediate sharing of the best available clinical information. This is crucial during a widespread and/or fast-moving ID outbreak caused by an unknown or unfamiliar pathogen. During such events, up-to-date treatment guidelines are not likely to exist. As new cases emerge in disparate locations, treating clinicians must have access to the knowledge of global experts and the ability to learn from the experiences of other clinicians who have treated patients with the same illness. Furthermore, to answer immediately critical questions, structured clinical trials must be conducted, and they may have to be developed rapidly and spontaneously. Currently, it can take weeks or months for clinical trials to be approved, and once a trial is complete, the results may not be available or shared for months or even years pending the review and publication of academic papers.

If we had a national (or international) network or consortium of academic medical centers, clinicians, and experts organized in advance to collect and distribute real-time clinical information rapidly during an ongoing health emergency, we would be much better positioned for response to an ID emergency. The USG should facilitate and support development of such a network.

Challenges to Meet

While the healthcare system is unquestionably better prepared today than it was in fall 2001 when the anthrax attacks occurred, significant challenges remain. Fortunately, we are fairly well positioned to meet them if we make use of and expand national resources that we have already invested heavily in, if we set and support rigorous research and development agendas, and if we work toward developing a system to support real-time testing and exchange of clinical data. All of these goals are attainable with focused effort and USG support.

References

  1. Toner E, Waldhorn R, Franco C, et al. The Next Challenge in Healthcare Preparedness: Catastrophic Health Events. January 2010. http://www.upmc-biosecurity.org/website/resources/ publications/2010/pdf/2010-01-29-prepreport.pdf. Accessed August 1, 2011.

  2. Toner E, Waldhorn R, Franco C, et al. Hospitals Rising to the Challenge: The First Five Years of the U.S. Hospital Preparedness Program and Priorities Going Forward. March 2009. http://www. upmc-biosecurity.org/website/resources/publications/2009/ pdf/2009-04-16-hppreport.pdf. Accessed August 1, 2011.

  3. Franco C, Toner E, Waldhorn R, Inglesby TV, O’Toole T. The National Disaster Medical System: past, present, and suggestions for the future. Biosecur Bioterror 2007;5(4):319-325.

  4. Zoler M. Is N-95 respirator really best in H1N1? ACEP News December 2009. http://www.acep.org/content.aspx?id=47239. Accessed August 1, 2011.

  5. Center for Biosecurity. Diagnostics for Gobal Surveillance: Turning Promising Science into Tools Needed for the Field. In press.