IOM Committee on Implementation of Antiviral Medication Strategies for an Influenza Pandemic

IOM Committee on Implementation of Antiviral Medication Strategies for an Influenza Pandemic

fi Who would be considered vulnerable to exposure in an outbreak? fi Where should the medication be dispensed? fi Other logistical issues?

Very high: : Exposure to ill persons & aerosols -- HCW performing aerosol generating procedures High: : Exposure to ill persons -- HCW, medical transport Medium: : High frequency close contact with the non-ill public or co-workers -- High density retail Lower: : Minimal close contacts -- Office employees http://www.osha.gov/publications/influenza_pandemic.html

fi Very high: Exposure to ill persons & aerosols HCW performing aerosol generating procedures fi High: Exposure to ill persons HCW, medical transport fi Repeated close contact with infected patients fi Frequent exposure to body fluids including sputum during clinical procedures

fi Metro/Urban areas Increased risk factors High volume of calls Population mobility Population density fi Rural/frontier areas Largely volunteer Limited resources Potential to wipe out entire response capability fi Basic Life Support fi Advanced Life Support fi Medical and Critical Care Transport fi Paid fi Volunteer

fi EMS agencies may choose to purchase antiviral drugs for stockpiling for several reasons Provide pre-exposure prophylaxis for employees probable occupational exposure to ill persons essential to a business operations certain critical infrastructure workers Anticipation/Fear

fi EMS/public health partnerships fi Respect for plans already in place fi Coordinate at the local level to maximize participation Access/convenience to workers All duty shifts

fi Financial implications fi Prioritization of EMS workers fi Security fi EMS worker perceptions Risk Ethics Family issues

fi States and private companies are increasingly challenged to ensure a reasonable state of readiness due to competing operational needs Cost of preparedness Overall expense Shelf life of product Recurrent need

fi Approval (who decides?) fi Active Agency rosters Proper identification of active members Administrative staff fi Inactive conundrum Members on paper only Certification/licensure status Could be called in to replace ill workers

fi Strict control/protection of stockpiles fi Protecting critical infrastructure to ensure EMS capabilities Isolation and quarantine considerations Operational lock-downs to protect unexposed workers at EMS stations and 9-1-1 call centers Facilitating access to the supply chain

fi Perfectionists fi High need for control fi Under usual circumstances, EMS providers prioritize patients, duty, and family ahead of self

fi Risk to self; Risk to loved ones fi Ethics Respect for Autonomy Principles of Beneficence and Nonmaleficence Duty to Care

fi Normal risk level of the working environment fi Healthcare worker's specialty fi The likely harm and benefits of treatment fi The competing obligations deriving from the worker's multiple roles Sokol DK. Virulent epidemics and scope of healthcare workers' duty of care. Emerg Infect Dis. 2006 Aug. Available from http://www.cdc.gov/ncidod/eid/vol12no08/06-0360.htm

fi Sokol: Healthcare employers have a set of reciprocal responsibilities toward their staffs, which include duties to inform, protect, and support healthcare personnel. fi BMJ article: 9 authors "could not reach consensus on the issue of duty of care, particularly regarding the extent to which healthcare workers are obligated to risk their lives in delivering clinical care"

fi Health authorities unable to quantify risk fi Higher risk to loved ones Even with vaccines and AV protection to workers-- inadvertent transmission to others via hair, personal items and equipment, nails, clothing, etc. fi Peer-reviewed journals starting to address ethical concerns in CRNBE response

Government Studies in acute and longterm care show protecting HCWs protects their contacts Limited resources Cost considerations fi Sector specific fi fi Peer-reviewed study--91% of paramedics would remain on duty if they were fully protected, this number falls to 38% if the respondent believed that his or her immediate family was not protected Maryland Study--53.8% of HCWs indicated that they would likely report for work during an influenza pandemic. Willingness to report for work was influenced by factors such as what role the individual has in a pandemic, existing knowledge, and especially risk perception

fi Protect state sovereignty fi EMS/Public health partnerships Prioritization Procurement Distribution fi Promote collaboration with local/county/regional health districts EMS PODs

fi Acknowledge the concerns of HCW fi Risk communication geared to HCW (don t single out EMS) and their families fi Education re: personal mitigation fi Maintain high priority for medical countermeasures and PPE to EMS workers

fi Potential alternatives to address family issues Provision of antivirals to workers families at government/employer expense, when feasible Availability of antivirals to workers families at employee expense, i.e. Risk/mitigation communication Cost-sharing at a rate negotiated by the federal government

Kathy Robinson, RN, EMT-P Program Manager National Association of State EMS Officials Phone: 703.538.1799 Ext. 1708 Email: robinson@nasemso.org