Ramaz Mitaishvili, M.D.
Glendale, CA

Health care personnel are among priority groups for antiviral chemoprophylaxis and vaccination. However, available supply of antivirals likely will be far less than the need and the efficacy of chemoprophylaxis may be compromised by antiviral resistance. If available, vaccine is also likely to be in short supply early in a pandemic. Assuming insufficient vaccine initially to protect all hospital staff, health departments and health care organizations should work together to define front-line health care workers who would have priority for vaccination or chemoprophylaxis. Absenteeism may result from illness, the need to care for ill family members, and possibly from fear of exposure and infection. As part of preparedness planning, health care organizations should develop strategies to cope with staffing shortages.

Strategies to increase available staff:

1. Ensure that the facility’s time-off policies and procedures adequately consider staffing needs in periods of clinical crisis.
2. Consider or expand hospital-sponsored sick care services for the children of hospital staff to reduce staff absenteeism.
3. Within reasonable limits of clinical competency, consider use of registered nurses and other health care providers serving in administrative positions to provide patient care.
4. Consider appropriate clinical care roles for trainees (such as medical or nursing students), retired health care providers, and community volunteers for some patient care roles and other functions such as patient or specimen transport and for maintaining good patient flow in crowded emergency department settings.
5. When vaccine becomes available, sponsor local immunization programs for all staff members, physicians and their families, and other at-risk members of the community.
6. Preferentially use immunized staff to care for those with suspected or confirmed influenza infection.
7. Generally, health care workers who have respiratory illness should be excluded from work to avoid infection of patients, many of whom are at high risk for severe or complicated disease. In a pandemic, and faced with critical staff shortages, such restrictions could be relaxed on a case-by-case basis, such that health care workers who have mild respiratory illness could provide care for cohorted influenza patients.
8. In addition to chemoprophylaxis begun before exposure and vaccination, other strategies to decrease the risk that a health care worker will be infected include good infection control and post-exposure chemoprophylaxis. Antiviral treatment using a neuraminidase inhibitor shortly after onset of symptoms can decrease the duration of illness and time missed from work as well as reducing the amount of viral shedding and risk to other staff and patients. Early therapy also is the most efficient approach to antiviral use when supplies are limited.

Bed Availability: Additional beds can be made available for those who require admission for influenza or its complications by decreasing other admissions, implementing more stringent triage, and decreasing the length-of-stay. Hospitals also may be able to add acute care beds in a public health emergency, although staffing those beds may be a limitation.

Strategies to increase the availability of hospital beds:

1. Review policies for scheduling elective procedures and develop guidelines and contingency plans to limit elective admissions and surgery. Decreasing elective utilization of health care facilities during a pandemic will increase bed availability, allow redistribution of staff and equipment, and may decrease the elective patient’s exposure to influenza infected persons. Consideration should be given to performing any necessary surgeries in a surgical ambulatory care center to reduce the likelihood of exposure to influenza infected patients in hospital.
2. Consider appointment of a triage officer to manage patient flow in the emergency department, including appropriate patient referral to other clinics within the facility or to local physicians’ offices or nontraditional care settings when emergency department care is not required.
3. Review and revise criteria for admission. Consider directing patients referred for admission by their physician to the emergency department where the need for admission can be directly evaluated (by a triage officer) in the context of bed and staff shortages.
4. Review guidelines and policies allowing expeditious transfer of patients between units, especially from critical care units, when indicated.
5. Develop plans and policies to promptly transport discharged patients home or to other facilities. Consider creating a patient discharge holding area or discharge lounge to free up bed space.
6. Ensure that the facility has effective rules for expediting patient discharge during periods of anticipated high demand. These rules might include allocation of a sufficient number of triage physicians and nurses to the appropriate services and procedures for discharge and transfer of patients to home, or other facilities.

Equipment/Supplies

Plan for the limited availability and increased need for equipment and supplies such as respirators, gurneys and supply carts within the facility and for potential disruption in the normal delivery of supplies and repair services. We would suggest to Abkhazian de-facto Government, as well as Georgian central Government include ventilators in a budget. Because a pandemic may not affect all areas simultaneously, it may be possible to shift some resources between areas; this may be most feasible if a pandemic wave already has passed through a community and ventilators become available rather than an area that has not yet experienced disease sending its equipment elsewhere.
Consumable resource needs are those specific to an outbreak of infectious respiratory disease, including hand hygiene supplies, gowns, gloves, and surgical masks, as well as other supplies associated with routine patient care. Since these types of supplies have no expiration, it would be possible to establish stockpiles (either in individual facilities or regionally).
In the event of a pandemic, local healthcare facilities will be the primary entity responsible for the treatment of ill persons, including dispensing antiviral medications. It is recommended that healthcare facilities maintain a supply of antiviral medications to be used for the treatment of ill persons, as the availability of such medications allows. Current evidence indicates the facility supply should include oseltamivir (Tamiflu); however the facility supply does not necessarily need to be restricted to oseltamivir as other antiviral medications such as amantadine, rimantadine, and zanamivir may be effective against pandemic virus strains.

Infection Control

Influenza viruses are spread from person-to-person, primarily through inhalation of small particle aerosols and large droplet infection. Influenza can be highly contagious, particularly among persons without pre-existing antibodies against influenza, such as young children during normal influenza seasons and anyone during a pandemic. The typical incubation period of influenza is two days (range one to four days). Viral shedding, and the period during which a person may be infectious to others, generally peaks on the second day of symptoms, but may begin the day before symptoms start, and typically lasts five to seven days in adults. Young children and immunocompromised persons may shed virus and be infectious for three weeks or longer. The amount of virus shed and the length of time of viral shedding may be prolonged during initial infection with a new influenza subtype.
Infection control practices for pandemic influenza are the same as for other human influenza viruses and primarily involve the application of standard and droplet precautions. Special guidelines for infection control may need to be in place during pandemic influenza, taking into account the likelihood that a high proportion of the population will be affected and that secondary infections are a major source of morbidity and mortality. Healthcare facilities, in addition to standard, droplet, and contact precautions, should consider the following:

1. Conduct annual staff education about the prevention and control of influenza.
2. Strongly encourage annual vaccination of staff.
3. Healthcare workers and visitors should wear a surgical mask when they are within three feet of the patient.
4. Consider separate waiting rooms for patients potentially infected with influenza
5. Patients should be educated about what they can do to decrease transmission of influenza to other patients, health care workers, and visitors. Information on Respiratory Hygiene/Cough Etiquette should be posted and communicated individually to patients hospitalized with respiratory disease.
6. Visitors should be limited as much as possible to reduce the likelihood of transmission of influenza among visitors, patients, and health care workers. The use of family members and volunteers to assist in patient care may be considered with documented policies and education in place.
7. Ideally, patients with suspected or diagnosed influenza should be in a private room. During a pandemic, private rooms are unlikely to be available and containment of infection is likely to be difficult. Consideration should be given to cohorting patients with active confirmed or suspected influenza infection. If for some reason cohorting is not achievable, at least 3 feet spatial separation should be maintained between the infected patient and other patients and visitors. Special air handling and ventilation are generally not necessary. It is recommended that all influenza specific bed management measures should be maintained for at least 7 days after onset of illness or longer if symptoms persist.
8. Limit the movement of patients with suspected or diagnosed influenza to essential purposes only. If a patient must be transported, the patient should wear a surgical mask to decrease the risk of virus transmission to other patients and health care workers.