It sounds like the plot of the next blockbuster movie. A third of the world's population is struck down by a deadly virus that spreads across the globe so rapidly that there is no time to develop a vaccine. Up to half of those infected - even young, healthy adults - die. But as health professionals know, this scenario is not just a flight of fancy. It could be the very real effects of the next pandemic flu outbreak, particularly if H5N1 (also known as highly pathogenic avian flu) is the virus in question, and it is this knowledge that is pushing not just federal and state government but organizations and businesses throughout the world to develop a strategy to tackle it.
Within colleges and universities, the burden of pandemic flu planning is likely to fall upon many student health directors, even at institutions with environmental health and safety departments. John Covely, a consultant on pandemic flu planning and the co-author of the University of North Carolina at Chapel Hill's pandemic plan, explains why this is so.
"Traditionally, emergency planning originates from public safety, or environment health and safety, but a communicable disease poses the biggest threat to students in group quarters. Thus, student health directors are often leading the emergency planning effort for the whole university, because the entire plan - not just the student health component - could be the difference in life or death for their students."
The importance of having a campus-wide plan that is ready - not just in the preliminary stages - when the pandemic strikes is all the more clear when you consider that, unlike seasonal flu, H5N1 has an increased risk for the typical student demographic of young, healthy adults. The startlingly high mortality rate of up to 60 percent is partly due to a protein, also found in the strain of virus responsible for the 1918 pandemic flu outbreak, which causes a response in a healthy immune system known as a "cytokine storm", often leading to respiratory failure and death.
Planning for such a massive and yet unpredictable event may seem a formidable task, but Dr. Anita Barkin, chair of the American College Health Association's pandemic planning committee, counsels that those universities and colleges that have yet to formulate a pandemic plan shouldn't feel overwhelmed by the work that lies before them. "Pandemic planning is about good emergency preparedness. The things we do to prepare for any emergency are the things we would do to prepare for pandemic flu," she explains.
Although the tragic Virginia Tech shootings this spring were a different kind of emergency, the issues are similar to the issues faced in the event of a pandemic flu outbreak. Coordinating resources, communicating with everyone on campus and deciding at what stage classes should be called off are questions that have to be answered in most emergency situations. Take your pandemic planning one step at a time, advises Barkin.
"The first step is to find out whether there is an existing emergency plan on campus," she says. "If there is, who is in charge of it? Health providers on campus should then take charge and begin to formulate the plan."
There are many unknown factors, but build the framework of the plan first with the elements you can be sure of. Form a committee with all key areas represented, including executive leadership. ACHA's Guidelines for Pandemic Planning provides a list as an example that may help you collate this. Identify the functions that will be critical in the case of a pandemic and the personnel on campus responsible for each of these, making sure there are enough people representing each function that should some become sick, the plan is not compromised. Identify decision makers, a chain of command, and what channels of communication are to be used. Finally, decide on the role of student health services. Many campuses will have the student health director as the key decision maker in the event of a pandemic, but for some it will be more appropriate for the student health director to have an advisory role instead. In any case, college health professionals will be crucial to the success of every plan.
The biggest question that is central to every campus-wide pandemic plan: when is the right time to send students home? Covely warns that universities cannot necessarily wait for cues from state public health departments before they make their decisions. "The university has to have its own in-depth criteria in advance of a pandemic, and the student health director should be very involved in developing those criteria."
Barkin suggests looking back to the 1918 influenza epidemic for context.
"In 1918, the virus spread across the country in three to four weeks. If you think about the fact that the virus traveled from coast to coast in that short a time when the primary means of long-distance transport was the train, and then you think about how much more quickly we can travel today by plane, that timeline is going to be compressed significantly."
In other words, don't wait too long to send your students home. Nor should your trigger for this decision rely on the geographical proximity of the virus to your campus alone. Covely explains:
"Geographical proximity is not definitive enough in this age when in a single day, there are 50,000 passenger flights throughout the world," he says. "Because New York City and Hong Kong have major international airports, epidemiologically, New York City is actually closer to Hong Kong than it is to Buffalo, so waiting to suspend classes until a confirmed case gets to your region, or within 500 miles, may be too late."
The factors that will determine how early you make the call to send students home will center on the composition of your student population. If your students are mostly from in-state, they will probably be traveling home by car and so you can wait slightly longer before canceling classes and closing the campus down. If many students live a long way away and are going to need to use mass transportation, you may have to act more quickly or risk being swamped with very ill students at a time when the local hospitals will not have the resources to help.
There are three main elements that will shape the logistics and the scale of your plan, and help you figure out the best trigger to send students home. Remember that, as Barkin comments, "The longer you wait, the higher the rate of infection, the less chance of being able to get students home and the less likely you can manage the burden of disease."
These factors are as follows:
Student demographics, particularly the number of students who live on campus and the number of non-local students who are likely to be dependent on care.
The size of your staff (taking into account that up to 50 percent may be sick at one time).
Your ability to stockpile enough basic supplies, including medications, as well as personal protective equipment such as respirators.
This is where things start to get more complicated, however. Most student health services can't afford to stockpile many medical supplies. "ACHA is running a survey on pandemic planning," reveals Barkin. "Of the schools that have responded, most have not stockpiled, or if they have, it's not a lot." This could clearly prove disastrous, and for many colleges is a manifestation of what Covely cites as one of the biggest challenges of pandemic planning for some universities: "getting buy-in from the executive leadership." Pandemic planning is by no means a cost-free exercise.
One tip if you are facing resistance from campus decision-makers over spending money on pandemic planning is to emphasize the fact that once you've formulated a response to a possible pandemic, you will have a robust emergency response strategy that can be adapted to fit virtually any emergency, whether it's evacuation in the event of wildfires, such as Pepperdine University faced recently, a terrorist threat, or an "active shooter". Investment in, say, developing a Web site with emergency information and updates can be a public relations bonus and a reliable resource. Villanova University's plan includes broadcasting SMS text messages and e-mails and using an emergency Web page for mass communication.
When you do know the scope of your resources, both human and financial, you can continue to flesh out your plan. Excellent resources can be found on ACHA's Web site: http://www.acha.org and http://www.pandemicflu.gov. A tip from the experts: be wary of developing your plan in a vacuum. "I know of a school that didn't know their gymnasium was being considered as a point of vaccination until they happened to find out in the course of an outreach program," Barkin relates. "The local health department hadn't informed them." This is very obviously a benefit of starting a dialogue with your local health services: you find out what they have planned and you can also coordinate your plans to add value and decrease the number of unknown factors.
Dr. Mary McGonigle, director of the student health center at Villanova University, says that their dialogue with their local health department led to Villanova being assessed and labeled a "push" site, a location that is self-sufficient in this type of emergency. She explains:
"In the event of a pandemic, we'd go and pick up supplies from the county and then administer medicine to our Villanova community. That includes students, faculty and their families."
Help from the county is a financial boon but being self-sufficient and staying local also lowers the risk of spreading the virus so rapidly. The dialogue helps your local health services too. If your local hospitals are likely to have a shortage of beds, they may want to use college dorms for surge capacity at the peak of a pandemic. In return, they may be able to offer you some resources, although research suggests that most hospitals have not had the budget to be able to stockpile effectively either.
Once you have your plan together, it's important not just to file it away and forget about it. "Planning for a pandemic is very much a work in progress, but it is often hard to keep up the interest in reviewing and updating plans, especially when H5N1 activity drops out of the news," explains Covely. Tabletop exercises are one way to test the effectiveness of a plan and a good way to maintain interest. Covely specializes in facilitating these tabletops and finds that they can significantly increase staff's buy-in as well as providing useful discussion points.
"Used before the planning begins, tabletops provide a way of educating employees and getting them interested in developing continuity of operations plans," he says. "They are excellent for post planning too, in order to test the plans. I am always amazed at the creative analysis and insight that comes from a tabletop."
The ongoing and fluid nature of pandemic planning is very much evident in some of the complex and thorny issues that have no definitive answer. These may need to be revisited and rethought as scientific discoveries are made, as you approach a pandemic, and if your college's resources change. One such issue is the availability of expensive antivirals. The federal government has announced that it is stockpiling them and coming up with a strategy for distribution, which might seem to take some of the financial pressure off student health services. Barkin however has a caveat. "I'm concerned that stockpiles would not be distributed in enough of a timely fashion to make an impact on the community. Katrina is a situation that has to come to mind."
Even if you did manage to persuade campus decision-makers to invest budget in stockpiling antivirals, a potentially challenging feat, there's a chance that they would be ineffective by the time a pandemic occurs, as overuse can cause the emergence of a resistant strain. Barkin explains that infectious disease experts are talking about using a treatment cocktail - Tamiflu plus one or two other agents - to protect against the emergence of resistant strains, but this would be prohibitively expensive for the average college health center.
Another ethical dilemma surrounding pandemic planning concerns who should get prepandemic vaccines. Scientists are developing vaccines based on the strain of avian flu that has been circulating in Asia, hoping that the vaccine would be enough of a match to combat the illness until a proper vaccine could be developed six months after the pandemic's emergence. But supplies of this prepandemic vaccine will be limited.
"Some of the conversations around who should get these prepandemic vaccines are very complex," says Barkin. "Should it be health care workers that get it, or public safety workers such as firemen? Should it be government officials, or the very young and elderly?" Recently, the federal government has announced a three-tiered approach to vaccination that it has developed in consultation with public focus groups and ethicists that places health care workers in the second tier. Whether your health center staff will receive the vaccine, whether it will be in a timely fashion, and how effective it will actually be, are all factors that will affect your pandemic plan greatly - and demonstrate how much of your planning has to leave room for the unknown.
One thing that is beyond question is the importance of student health services acting now. Formulating a pandemic plan may be a slow and ponderous task, but there's one vital aspect that will slow the spread of a pandemic and can be tackled by your department immediately without getting tangled in red tape and endless meetings. Barkin elaborates:
"Every single student health service needs to be involved in educational outreach efforts to distribute information on the role of flu vaccinations, cough etiquette, when to come to work and when to stay at home if you are ill and the importance of creating a personal preparedness plan in the event of a pandemic."
This public health education can be a collaborative effort with human resources and residence life staff. Covely agrees and even suggests extending the scope beyond campus boundaries. "It's part of being a good and responsible neighbor to the community, and it has tremendous public relations benefits to the university," he says.
The collaboration required in pandemic planning can build bridges, but be prepared for it also to be particularly challenging. McGonigle relates:
"At Villanova, we're still in the stages of planning. We've done a lot. But I would say the most difficult part is trying to connect and communicate with all the different departments on campus and plan for all the different scenarios."
Indeed, planning for all contingencies - not just the obvious problems of effectively treating the sick and minimizing the mortality rate, but also coping with disruptions to services and shortages of supplies caused by huge absenteeism and the ensuing breakdown in the transportation system, and questions such as whether to pay staff if the campus is shut down - has caused planning at many colleges and universities to take much longer than anticipated.
Pandemic planning is also dogged by a sense of unreality: could something this vast really happen? (The answer, as every health professional knows, is "yes", and is a question of when and not if.) Media coverage of pandemic flu is patchy and focuses on sensational stories rather than the need for personal emergency preparedness. Because it's not an issue in the forefront of the public's mind, it's sometimes hard to conjure up the necessary sense of urgency, particularly because there is always some issue on campus demanding more immediate attention. Barkin sympathizes, but has some sobering last words on the subject.
"Recently, the issue of pandemic flu has fallen off the radar," she says. "We've been talking about it for two years and now there are other pressing issues that have pushed it to the back burner. But the issue of pandemics is not going to go away. We've had them throughout history and if you look at the patterns, we're due for a pandemic soon. It may or may not be H5N1, and it may or may not be on the 1918 scale. What we cannot ignore, however, is the planning that's needed, because in a pandemic, health centers and heath care providers will be looked to and expected to know how to respond."
