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The Five People You Meet in a Pandemic - and What They Need from You Today

The Five People You Meet in a Pandemic - and What They Need from You Today

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Published by The Hastings Center
The “five people” described in this document are representative community members who are first responders. Each will have particular duties during a pandemic. Each will rely on planners to anticipate and discuss ethical challenges; to develop ways to make fair rationing decisions; and to be transparent before, during, and after the crisis. Planners can use these five people as tools for their own discussions—and may identify other representative community mem- bers who will rely on them.
The “five people” described in this document are representative community members who are first responders. Each will have particular duties during a pandemic. Each will rely on planners to anticipate and discuss ethical challenges; to develop ways to make fair rationing decisions; and to be transparent before, during, and after the crisis. Planners can use these five people as tools for their own discussions—and may identify other representative community mem- bers who will rely on them.

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Published by: The Hastings Center on Feb 27, 2010
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05/22/2013

 
I
n April 2007, all state public health directors sub-mitted their pandemic influenza preparednessplans to the Centers for Disease Control (CDC), inresponse to an assignment and template from theNational Strategy for Pandemic Influenza, coordinatedby the Departments of Health and Human Services(HHS) and Homeland Security. Officials wererequired to describe how they will deploy public agen-cies and private sector partners in the event of an out-break, and in coordination with federal agenciesresponsible for surveillance, vaccine development, thedistribution of antiviral medications, and restrictionsaimed at controlling the spread of the virus. The fed-eral agencies will review and score the states’ plans.In June 2007, the
 American Journal of Public Health
published a survey of the federal and state pandemicplans published to date.
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 The authors of this report noted that the federal template and scoring criteria did not require states to be specific about the ethicaldecisions that are integral to pandemic planning andto public health and safety during a crisis. As a result,
 few plans contain concrete guidance on how offi-cials and first responders can make ethical deci-sions—fair decisions—under immense pressureduring a sustained crisis
, or on how to allocate lim-ited resources fairly. While the CDC has publishedrecommendations for rationing vaccines and anti-viralmedicines, these are not the only scarce goods and
Bioethics Backgrounder
Ethical decisionmaking during an influenza pandemic
 The Hastings Center
 The Five People You Meet in a Pandemic—and What They Need from You Today 
by Nancy Berlinger and Jacob Moses, The Hastings Center
Additional copies of this Bioethics Backgrounder can be downloaded at www.thehastingscenter.org or atwww.providence.org/oregon/Programs_and_Services/Ethics/Default.htm.
Who’s got the plan?
The national Pandemic Influenza Preparednessand Response Plan
10
describes the followingresponsibilities of the Federal government during apandemic:• Surveillance• Epidemiological investigation• Development of lab tests• Vaccine development, testing, evaluation,deployment, safety evaluation; deployment ofantiviral agents in the Strategic National Stockpile• Enacting travel or other quarantines• Facilitating medical and public health communi-cationsThe Federal plan requires that state plans cover
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:• Identification of public and private sector part-ners needed for effective planning and response• State coordination with federal efforts aimed atsurveillance and infection control• Integration of pandemic influenza planning withother public health planning activities overseen byfederal agencies, including the CDC’s PublicHealth Preparedness program and the HealthResources and Services Administration (HRSA)’sHospital Preparedness program• Coordination with local authorities, such ascounty and city public health departments, toassist in developing local plans on which stateplan depends• Development of data management systems• Coordination with adjoining jurisdictions, includ-ing other states and regional authorities
This publication was produced incollaboration with The ProvidenceCenter for Health Care Ethics atProvidence Health and Servicesand made possible through a generous grant from theProvidence St. Vincent Medical Foundation.
 
services that will need to be distributed fairly during a pandemic.
2
 The ethical duty to plan
 When a wave of influenza deaths begins in a com-munity, it will be too late to start thinking about ethics, or to alter public health and medical and other social systems so care is organized more ethically.Foreseeable ethical challenges—how a community  will make fair decisions about using scarce resources,protecting public health, and keeping basic servicesrunning—must be discussed today.
3
 The ethical duty to develop rules and tools for making fair decisions
 To be fair is to provide individuals and groups with what they need: food, water, shelter, health care, safe-ty, information, justice. A public health emergency willrequire rationing of these necessities in the interest of the community’s survival. When planners know there will not be enough of what people will need, they havea duty to create and test the rules and tools that willhelp first responders make fair decisions during a cri-sis. Samples of rules and tools are included in thisdocument. Deciding what “trigger”—such as the dec-laration of a state of emergency by a state’s gover-nor—will alert first responders to the epidemiologicalconditions that authorize them to begin using thesepandemic guidelines and other rules and tools areamong the responsibilities of pandemic planners.
 The ethical duty to be accountable to one’s com-munity 
Every community member has a stake in its pan-demic plan, because every community member has a stake in the community’s survival. Planners have a duty to make their ethical reasoning clear, and toshare it with community members. They can do thisthrough public meetings, by posting draft versions of rules and tools on websites for public review and com-ment, and by including experts in communication andpublic education in planning activities.
 The “five people”
 The “five people” described in this document arerepresentative community members who are first responders. Each will have particular duties during a pandemic. Each will rely on planners to anticipate and
2
Flu Facts
Good ethics starts with good facts. Here are the cur-rent facts, and expert opinions, on the potential for flupandemic:
International public health experts agree that anew flu pandemic—possibly triggered by a mutat-ed avian flu such as H5N1—is inevitable;
that cur-rent vaccine stockpiles are incapable of preventing afuture outbreak; that current antiviral drugs will beeffective only in limited conditions; and that thenation’s hospitals do not have enough ventilators forpatients who will be sick enough to need them.According to the CDC, more than 60 countries haveconfirmed cases of H5N1 in animals.
12
The WHOreports 319 cases of H5N1 among humans, resultingin 192 deaths from H5N1 to date.
13
Although its trans-mission rate among humans is still low, H5N1 has afatality rate of more than 50%. The 1918 flu had afatality rate of just 2%—and killed 50-100 million peo-ple.
14, 15
Reconstructions of the 1918 flu strain (H1N1) sug-gest that flu strains that cause acute inflammation canalso make flu victims vulnerable to opportunistic, con-tagious infections such as bacterial pneumonia. H5N1shares a similar pathology to H1N1.
16
H5N1 is just one flu strain capable of mutating into apandemic-causing virus. It receives much of the scien-tific and public health attention because it has alreadyspread from birds to humans—and in very rare casesfrom humans to humans.
17
Failures to control other flustrains within bird populations, and the rapid growth ofpoultry-processing industries worldwide, are increas-ing the likelihood that a pandemic strain will develop.
18
In April 2007, the FDAapproved the first vaccineagainst avian flu.
19
At this time, the federal govern-ment purchased enough vaccine for the NationalVaccine Stockpile contained enough of the vaccine totreat 6.5 million people: the target is 20 million stock-piled doses for public health workers. However,experts strongly question the vaccine’s usefulnessand effectiveness.
20, 21
Effectiveness could be furtherreduced by the rapidly mutating nature of a flu virus:the virology of a pandemic strain would certainly differfrom the H5N1 strain the stockpiled vaccine has beendesigned to combat.
22
At most, the stockpile will pro-vide a stopgap in the initial days of an outbreak until amore effective vaccine can be developed from theactual pandemic strain.
23
It will take 6-8 months fol-
 
discuss ethical challenges; to develop ways to makefair rationing decisions; and to be transparent before,during, and after the crisis. Planners can use thesefive people as tools for their own discussions—andmay identify other representative community mem-bers who will rely on them.
From well-meaning words to real frameworks for real communities: the regional public healthplanning challenge
 An influenza pandemic will force first responders,including health care workers, to think and act differ-ently than they normally do. In a crisis, they needclear protocols to follow. But if these rules seemunfair, or don’t match the situation at hand, the bur-den on first responders will be excruciating. As a soci-ety, we must not shift the burden of deciding how tobe fair onto the same first responders we will rely onto treat the sick and maintain public health and safety.Pandemics do not respect boundaries. What hap-pens in one city, county, or state will affect its neigh-bors. Yet home-rule traditions are strong: we havenow had 50 separate conversations about pandemicplanning. We have also had 5,000 other conversations, as thenation’s hospitals developed their own pandemicplans. While some hospitals have collaborated in plan-ning with their competitors, others have worked inisolation. A pandemic will force competitors tobecome collaborators. We are now having 3,066 more conversations, aseach county public health department grapples withregional planning needs, at the level where state plansand local health and safety resources must meet.Major cities in multi-county and multi-state regionsare also responsible for integrating federal and stateplans with the plans drafted by area hospitals.Regional planners at the civic, county, multi-county,and multi-state levels must identify gaps in state andfederal plans, including the absence of clear ethicalguidance. They also need to identify gaps in their local hospitals’ plans: are hospitals in the same region working from the same epidemiological models, or are they planning for different pandemics? Are somehospitals better prepared or better equipped than oth-ers? How can regional planners encourage collabora-
3lowing the identification of the outbreak strain for aneffective vaccine to be available.
24
The antiviral Tamiflu is effective only when takenwithin the first 12-48 hours following the onset ofsymptoms.
25
Tamiflu-resistant flu strains have beenidentified.
26
When pandemic influenza hits, most hospitals’venti-lators will already be in use by critically ill patients.Rationing access to available ventilators—and to oxy-gen and staff to operate them—will be an inevitablepart of patient care during a pandemic.
Experts also agree that a pandemic will profound-ly disrupt daily life.
If vaccine supplies are limited tothe most essential workers, the most effective publichealth strategy will be restrictions on public gatherings,and quarantine. Few living Americans have ever experi-enced these conditions for sustained periods.Discussing how compromised communities will func-tion during a prolonged public health emergency, howemergency policies can protect—or harm—vulnerablegroups within communities; and who will be capable ofand responsible for making fair decisions as they ariseduring a prolonged crisis, is part of the ethical duty toplan.CDC guidelines released in 2007 recommend clos-ing schools, canceling public gatherings, staggeringworking hours and voluntary quarantine in the event ofan avian flu outbreak.
27
According to a report by theTrust for America’s Health report, the US economycould lose three working weeks of productivity fromworkers who are ill, are caring for sick family mem-bers, or are unable to get to work.
28
As normal infrastructure and supply chains are dis-rupted by illness or quarantine, communities may faceshortages of clean water, safe food, utilities, and othernecessities. Hospitals will face the same shortages asthey care for waves of patients and attempt to main-tain safe conditions.
29
The secondary consequencesof a pandemic—such as outbreaks of diseases asso-ciated with poor sanitation or with interruptions inaccess to primary care, and the disruption of outpa-tient care for persons with chronic conditions—havethe potential to damage the public’s health beyond theobvious threat of pandemic influenza itself.

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