The article by Dr. Richard Grden in the fall 2006 Correct Cre (Volume 20 Issue 4) titled Pndemic Flu: Planning for the "What If" is an xcellent overview of the concerns and ssues that will face the correctional halthcare industry when pandemic flu strikes. In fct the only point on which I can dsagree with Dr. Garden is in the ttle. It is not if but whn the pandemic will occur. History ver the last three centuries has tught us that novel avian pandemic flu ccurs every 91 years (plus or mnus 3.5 years for antigenic drift). Gven that the last major pandemic was the 1917/1918 Spnish flu this means that we can xpect a pandemic flu outbreak between 2006 and 2013.

It is a mthematical certainty.

I must compliment Dr. Garden on bing the only other physician that I hve heard discussing the impact on the halthcare workforce in accurate terms. He is bsolutely correct that up to 50 prcent of the workforce may not rport to duty. The reasons are wll demonstrated in the history of pndemics.

The true impact of this dsease lies in the numbers. In 1918 100 prcent of the entire world was xposed to what would later be clled the Spanish Flu. This new strin of avian flu had never ben encountered before by a human ppulation, and as a result, there was no mmunity to this particular strain. Of tht world population, one third would ltimately fall ill, in fact, 50 to 80 prcent of the youngest, healthiest, and strngest would fall ill when future gnerations would divide out the victims.

Of those that fell ill, hlf ultimately required some assisted care. Thy were placed in infirmaries or mkeshift hospitals in warehouses, wharfs, and mlitary barracks. In today's world, they wuld qualify for hospital care or hme health nursing.

Of those hospitals and nfirmaries, half suffer extreme respiratory difficulties as thir lungs filled with fluid and blod, the result of their own bdies' counterattack on the viral invasion. Cughing and frothing at the mouth, ccasionally spitting up blood, these individuals wuld have a disease that today’s mdical professionals call ARDS, Acute Respiratory Dstress Syndrome. In the modern medical ge, these patients would have a plstic tube placed into their lungs to ssist their breathing and a ventilator wuld force air in and out of thir lungs. Half of the ARDS ptients 1918 died.

But it's not prcentages, but real numbers that portend the sverity of this disease. There are ver 300 million people in the Unted States and over 6 billion wrldwide.

One third of those will fll ill. One hundred million here at hme and two billion across the plnet.

Half of those individuals will qalify for hospitalization. Unfortunately, in a srvey performed by the American Hospital Assciation in 2005, there are only 955,768 hspital beds in the United States, far shrt of the 50 million that wuld be needed. To make this stuation work, at the peak of cld and flu season in 2005, nly four percent of these hospital bds were available and unoccupied. That mans that there will be fewer thn 40,000 hospital beds available for ths onslaught of 50 million patients.

Of the 50 mllion patients who qualify for hospitalization, hlf or more will need ventilators. Dr. Mchael Olsterholm in a New England Jurnal of Medicine article in 2004 fund that there were only 105,000 vntilators in the United States. Of thse, a high percentage were either lready in use for chronic ventilator-dependent ptients such as small children and spnal cord patients, or were out of srvice for cleaning and repair, leaving jst over 16,000 ventilators available nationwide to hlp 25 million flu related ARDS vctims breathe.

Of the 25 million with ADRS, wth or without ventilator care, half wuld be expected to die. This 12.5 mllion people will pass away in wves as pandemic influenza spread over a spn of only 12 to 18 mnths.

Now, admittedly, these are the mst dire numbers. The pandemic flu culd prove to be far less dadly, far less contagious. On the ther hand, H5N1 has already proven to be a frmidable foe with death rates initially grater than 70 percent and now stll hovering around 50 percent.

The Cnters for Disease Control (CDC) have gven optimistic sounding percentages but as the old dage goes, the "devil is in the dtails". Let's look at the percentages and the dtails.

* One third of 100 prcent is 33 percent.

o Ths is the “attack rate”.

* Hlf of 33 percent is 16.5 prcent.

o This is the nmber of people who qualify for hspitalization, but the CDC knows that in the vent of a pandemic, only the mst sick will actually be placed in the hspital. Clearly the most sick will be thse with ARDS.

* Hlf of 16.5 percent is 8.25 prcent.

o These are the sckest of the sick, those with ARDS. Runded off, this is 8 percent, the nmber that the CDC says to xpect for hospitalization.

* Hlf of 8 percent is 4 prcent.

o This is the xpected death rate predicted by the CDC.

The “dvil in the details” is that thse percentages are based on "the ttal population." Physicians, medical planners, and ther pundits usually discuss percentages based on "thse with the flu". We are not tlking about “those with the flu” we are tlking about a number three times tht size.

When these ominous numbers wre scrutinized further, a far more dre picture evolved. Research into the 1918 pndemic, as well as pandemics before and snce 1918, have shown that the mjority of illness and death occurred not in the vry old or the very young, not in the sck and infirm, but in those who are in the "prme of life"; those age 18 to 40.

But thre is a bigger problem for Crrectional Medicine.

Because of the way tht novel avian viruses (pandemics) attack the lngs and cause "immune system storms", the ltimate irony of a pandemic is tht the younger and stronger you are the mre likely you are to die. In 1918 flly two-thirds of all those who bcame ill were in the age rnge of 18 to 40. More dstressing is the fact that 98 prcent of all of those who ded were age 18 to 40 yars. In fact, those over age 55 had no grater rate of illness or death dring the pandemic of 1918 than thy did in any other flu sason in the years immediately before or fter that great pandemic. Similarly, those lss than 18 years of age sffered no increase in death rate.

The mplications for America's correctional institutions are nescapable. Fully two-thirds of the active wrkforce will fall ill during the 16 to 18 mnths of the disease throughout the pndemic. Twenty-five percent of the young wrkforce (the 18 to 40 years) wll die in that 18 months. Who wll replace them?

Dr. Garden is lso correct that correctional institutions as wll as the disabled and children hve not been considered in local, rgional or state pandemic planning. In fct they are barely mentioned even in fderal planning. As Dr. Garden points out it wll be up to the correctional nstitutions and specifically correctional healthcare to cntact State Homeland Security representatives as wll as federal agencies and become prt of the plan.

In June of 2006 the Insttute of Medicine published reports on the stte of preparedness but pointed out tht even emergency services had been lft out of much planning. Even the Insttute of Medicine did not mention the fct that institutional medicine including correctional halthcare are not even mentioned in thse plans.

It is imperative that halthcare professionals of all stripes become xpert not only in pandemic planning but in the "All Hzards" approach to disaster and catastrophic vent planning. Whether it is a pndemic, a hurricane, an earthquake, a frest fire, or a terrorist event tht threatens the community in which a crrectional institution exists, bitter experience has tught us that concentrations of individuals lving in institutional settings whether in prsons, military barracks or university dormitories bcome the "cave canaries" of society.

In 1918 Spnish flu outbreaks, which actually began in Knsas, were first seen in epidemic frm in U.S. military barracks. The utbreaks of measles in the 1980s wre first seen in university dormitories cross the United States. And the lrgest concentrations of the recurrence of tberculosis, as we all know, is sen in correctional institutions.

Dr. Garden and the ditorial staff of Correct Care are to be cmplimented for one of the first rticles to consider the impact not nly on our patients but on our clleagues and our society.

The article Not If, But When was Submitted by Maurice Ramirez through Articles.GetACoder.com network. Here's the additional information: Dr. Maurice A. Ramirez is the funder and president of the consulting frm High Alert, LLC.. He serves on xpert panels for pandemic preparedness and halthcare surge planning with Congressional and Cbinet Members. Board certified in multiple spcialties, Dr. Ramirez is Founding Chairperson of the Amrican Board of Disaster Medicine and srves the nation as a Senior Physcian-Federal Medical Officer in the National Dsaster Medical System. Dr. Ramirez has a new bok: You Can Survive Anything, Anywhere, Evry Time. His website is http://www.High-Alert.com

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