Community Preparedness

Preliminary considerations:

• There will most likely not be a targeted vaccine until about 6 months after pandemic has begun; any vaccine prepared ahead of the pandemic will likely render partial protection
• There will most likely not be enough antivirals for treatment, let alone prophylactic use
• Assume a quarter to a half of the public will become infected over a 3 month period (a flu wave, of which there usually are 3 — the worst being the 2nd — a few weeks or months apart) and 3/4 to a half staffing everywhere for various durations
• Virus will be shed before symptoms appear (which can be 3 - 6, up to even 17 days) and after symptoms (21 days for children, 3–5 days for adults, longer for the immunocompromised)
• Children and otherwise healthy young adults are disproportionately at risk
• All bodily excreta will be very dangerous, especially feces and sputum/mucus; virus often multiplies in gut and diarrhea is often first symptom, preceding respiratory symptoms
• We will probably need two or more times the beds and ICU facilities
• There will probably be mortality of at least an extra 50% beyond normal; a high percentage of these are likely to be under 65 years old, which comprise workers in essential services
• Most patients should probably be treated in the home, or if more critical, in secondary ICU-like set ups in schools or other unused locations
• Hospitals will need to continue their usual work and erect a firewall to protect vulnerable inmates
• Childcare and family nursing responsibilities will strain ability of healthcare workers and other essential infrastructure workers to provide services
• Public services such as water, power, waste disposal, communications, and transportation will likely be intermittently interrupted
• Deliveries of food and other essential commodities may be disrupted
• There may be civil disorder due to shortages and desperation

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City functions:

• Close schools and other (nonessential) places where people congregate
• Stockpile materials, medicines, face masks, gloves, antiseptic cleansers, wipes, etc.
• Set up vaccination priorities (in conjunction with medical personnel) in a logical way that puts essential personnel first: medical, police, essential waterworks, power, communications, waste and morgue workers; then children and adults, preferably those latter who commit to serve as neighborhood or healthcare volunteers (if we should be so lucky to have vaccine at all)
• Policing will be needed to guard hospitals and pharmaceutical stockpiles
• Develop plans to keep essential services operational; establish minimum staffing level requirements
• Establish lines of succession in critical positions
• Coordinate essential commodities deliveries and rationing
• Set up a city-based delivery network with designated staging areas
• Essential pre-purchased supplies could be dropped at neighborhood staging areas for distribution. Delivery personnel should be sufficiently safe if they do not make contact
• Establish emergency fuel supplies
• Negotiate with private water companies to utilize water delivery trucks
• Include area for public information updates on website and arrange with local radio & TV for regular accurate official updates (assuming media is functioning); utilize ham radio
• Institute Cisco system linking emergency radio networks
• Establish guidelines or rules for (voluntary?) quarantine: home isolation, isolation of contacts of known cases, restriction of movement, requirements for use of face masks
• Restrictions on airports and international and national travel as well as public transportation
• Ports and shipping: sterilization procedures for certain goods entering
• Curfew should there be unrest
• Insure that institutions where people live together such as nursing homes or prisons are prepared
• Consider how to deal with the homeless, who will be particularly vulnerable and thus hazardous
• Set up temporary morgues; body recovery teams with prepared vans that completely isolate corpse and protect drivers; body disposal in least potentially infective way, cremation encouraged
• Videotape school classes to put on TV or the internet so education can continue at home
• Gilead, the company that created Tamiflu but licensed it to Roche (and is suing to get it back), is based in California: appeal to them to make it invoking compulsory license (long shot)
• Explore the possibility of temporarily taking over hotels or motels for secondary treatment centers. They would be preferable to school facilities, as they already have beds and bathrooms
• Issue recommendations to all employers to encourage and facilitate telecommuting and teleconferencing if possible
• Levy a tax for preparation; lobby state and federal government for city funding
• Fuel shortages are bound to cause difficulties. [If possible, acquire and use small fleet of electric or plug-in modified hybrid Prius (see calcars.com) cars, charged via solar panels (if possible using Toshiba’s high-capacity lithium ion batteries — 80% charge in 3 minutes, 100% in 10; due to be made available commercially in 2006)]

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Hospital functions:

• Provide vaccine (if available) or prophylactic and therapeutic antivirals to healthcare workers to encourage continued service
• Set up mobile nursing units (part of firewall) with portable antiviral air filters for using in sick rooms (to protect the workers) as well as traditional protection
• Establish some means for healthcare workers’ children to be taken care of during shifts; possibly uninfected neighbors working at home
• Establish hotline for immediate assistance from mobile nursing units
• Establish teleconferencing and other communications capability for conferring with healthcare professionals
• Set up public information web pages and blog for Q&A; establish community liaison office; prepare and provide public education materials concerning flu and nursing procedures
• Stockpile supplies, vaccines, antibiotics, and antivirals, IV kits, fluids, O2 concentrators, ventilators, etc.
• Volunteer vetting and training: vaccination, administering meds, nursing assistance, testing for H5N1 (if possible), errands, etc.
• Establish minimum staffing levels; identify essential personnel; establish lines of succession
• Oversee secondary location set up and personnel (part of firewall)
• Suspend elective surgeries
• Close hospital wards to visitors
• Ensure critical functions such as waste disposal, backup power, supplemental water purification, laundry, sterilization, etc., with contingency plans for personnel shortages and service outages
• Transport seriously ill patients to secondary locations (EMT? City? neighborhood volunteers?)
• Documentation and data collection for analysis
• Air conditioning or forced air heating should be modified to eliminate viruses (UV, ozone, high filtration) in secondary facilities. Switch to radiant heat in winter and ice in summer
• Stockpile and establish a rental/delivery system for oxygen concentrators and ventilators
• Hire more respiratory therapists if possible but ensure their safety throughout the pandemic; train nurses in some RT techniques
• Pull doctors in from private sector corporate entities (which may be shut down anyway)
• Establish or lobby for a way to allow doctors licensed elsewhere or with lapsed licenses to practice during an emergency such as a pandemic
• Regular decontamination of patients’ quarters in secondary facility; need expanded morgue facilities
• Grief counseling will be in high demand
• Probenecid apparently doubles the half-life of Tamiflu in the body (see link to Reuters news story)

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Neighborhood functions:

• Organize neighborhood around avian flu contingency
• Archive information about each neighbor, emergency contact information, required medicines, pets, location of critical items on property such as medicines, special skills each can bring to bear in emergencies
• CERT training; first aid/CPR training
• Neighborhood education and news updates via newsletter, websites, email lists or phone trees
• Establish liaison with local hospital, healthcare professionals or city health services office
• Set up communications node (if communications are still up and running) or point persons and runners; maintain contact with neighbors
• Ham radio - have one licensed operator
• Keep track of all cases; transport afflicted when necessary (using personal protective equipment)
• Stockpile goods and move resources to where needed to prevent waste or shortage
• Establish staging areas for deliveries
• Immunized (via vaccination or flu survival) persons hopefully volunteer to run errands and help with nursing
• Consolidate errands to minimize contact in public places
• Purchase portable ventilator to share
• Elect a neighborhood “sheriff”; consider an armed guard if there is civil disorder

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Public Education:

• Hygiene considerations: hand washing, cough technique, awareness of infectivity on surfaces and cleaning techniques; special effort to train children; use video to demonstrate
• Importance of flu shots and pneumovax
• Importance of staying home when ill or if exposed to A(H5N1)
• Material preparations such as stockpiling food, water, household basics, etc
• Advance planning such as how to educate children pulled from school and working from home
• Teach basic nursing skills such as taking blood pressure, pulse, temperature, respiration rate
• Teach public how to identify A(H5N1) and specific nursing measures for home care; videotape classes for broadcast on TV and web for the public
• Encourage businesses to make contingency plans to accommodate social spacing via telecommuting, teleconferencing, etc; if employees can work from home, this is optimal