Political Borders, Health-care Issues Complicate Pandemic Planning

"Most public health experts who are leading planning efforts for an influenza outbreak are focusing on specific geographic areas, usually counties, as defined by political lines," said George Avery, an assistant professor of health and kinesiology and member of the Purdue Alternative Care Site Planning Team. "This is problematic because if there is an outbreak, planners need to take into account the people and health-care systems that are or are not around them.

"Counties that border other states may experience nonresidents seeking treatment in their area, while other counties may be home to the only isolated hospital system in the region and can expect the population from other states to travel there for care. Health care, especially in a crisis, is not defined by county or state lines."

For example, instead of each Indiana county health department making plans for its individual county, plans should be developed, or at least coordinated, regionally, Avery said.

Members of the Purdue Alternative Care Site Planning Team interviewed public health planners in 13 of Indiana's 92 counties from November 2006 to August 2007 as part of a pandemic planning gap analysis. The counties are Allen, Clay, Dearborn, Fulton, Huntington, Lake, Johnson, Montgomery, Orange, Posey, Randolph, Sullivan and Warrick. Purdue's Healthcare Technical Assistance Program assembled the team to look at issues about planning for alternative care sites and other surge capacity issues during a pandemic such as staffing concerns, medication supplies, and medical equipment access and health-care system and insurance limits.

The team's findings will be published online at the Journal of Homeland Security and Emergency Management.

Influenza hospitalizes 200,000 Americans annually and kills 36,000. In 2005 global concern was raised about a possible influenza pandemic because the number of human deaths related to bird flu was increasing in some Asian countries. There is concern that if the virus were transmitted human to human, a global outbreak could result in millions of deaths. As a result, federal, state and local leaders continue to plan.

"Another significant planning concern is related to staffing, especially at alternate care sites," said Mark Lawley, an associate professor of biomedical engineering who specializes in health-care delivery systems and is part of the research team. "During a pandemic, we can expect that caregivers will become ill, some caregivers will be reluctant to work and others will stay home to care for their own family members. Many planners are suggesting alternate care sites during an outbreak, but finding additional staff members for these units will a big impediment."

As a result, alternate sites often are not a feasible alternative, Lawley said. Also, the strain on the work force will likely affect the standard of care.

"The public has expectations about the standard of health care," he said. "For example, doctors prescribe medications and nurses administer them, but what happens if one group is understaffed during a crisis? How are roles reassigned and how is that communicated to the patients?"

In addition to staffing and community coordination issues, the researchers also found that misunderstandings about projected mortality and illness rates are creating panic.

"In several counties, many planners are anticipating devastating impacts that even exceed the worst case scenarios historically," Avery said. "The confusion results in a sense of helplessness among some planning teams because they believe any planning will be rendered useless by the magnitude of the problem."

To counter this, the researchers suggested more explanations by federal, state, international and academic experts about statistics and surveillance.

The research team also observed some contradictions in planning efforts. Counties planned on limited resources and expected to compete among themselves for basic medical supplies and other necessities, while at the same time, the plans acknowledged assistance would be sought from external groups, such as the National Guard or governor's office.

The other authors of this study are Purdue professors Barrett Caldwell and Dulcy Abraham, as well as former and current Purdue graduate students Sandra Garrett, Marshall P. Durr, Feng Lin, Po-Ching C. DeLaurentis, Maria L. Peralta and Alice Russell.

Purdue's Healthcare Technical Assistance Program was launched in 2005 as partnership with the Indiana Hospital Association and Regenstrief Center for Healthcare Engineering based at Purdue's Discovery Park. In addition to performing pandemic planning gap analyses, the program is focused on improving the health-care provider system, public health system, control of employer-paid health-care costs and medicine safety.

The Indiana State Department of Health funded this study. The Purdue Alternative Care Site Planning Team will continue to assess pandemic planning efforts.