In April of last year (here http://forums.homedialysis.org/showpost.php?p=6101&postcount=1 ) I asked:
“Should we give it [pandemic] as much or less consideration as we do other natural disasters – from earthquakes to ice storms – or is this something beyond what has been seen and what is prepared for?”
No one answered my question but I have continued to ask. Now I have my answer.
Yes. The answer is manifest, the answer is yes. Yes, pandemic flu is different from any other disaster I can think of threatening the provision of dialysis. Yes, if the CDC pandemic influenze planning scenario hit in the next two years, it would be the equivalent of an Earth destroying asteroid for the renal industry. Planet Renal would be distroyed.
In this post (here: http://forums.homedialysis.org/showpost.php?p=11443&postcount=36 ) I outline the variables that are unknown and that will determine the severity of a flu pandemic.
“What percentage of the population will catch the virus once it can pass easily among people? This “clinical rate” is a key number and there is not a lot of data on how many people in a normal flu season catch the flu and there isn’t any data on what percentage caught the flu the last time a pandemic occurred. In my reading the usual number is 30 to 50% of the overall population will catch the flu. A 50% clinical rate is used by most of the planning models that I have seen.
Of the people who catch the virus, what percentage will die? To date the case fatality rate (CFR) for H5N1 is 50% overall, however, most experts think this number will come down if the virus recombines into a version that can pass easily among humans. The low end of the range of CFRs is 2 to 5%.
The pandemic would hit in three waves, it is thought that the second wave would be the worst. I think a very optimistic prognostication about the worst wave would be for 30% of the population to get sick and a CFR of 2%. This is, as near as I can tell, the best case scenario.”
This post is not exactly accurate. The CDC scenario foresees a 30% attack rate (which is the term I should have used, not clinical rate) and a 2% case fatality rate (though the implications of some planning decisions are that they are planning for a 6% over all fatality rate). One question I need to research is: what exactly is meant by the attack rate?
Does the attack rate mean that after two years, once the flu has run its course, that 30% of the population will have had the flu? Or does it mean that with each wave (it is reported that historically there are three waves) 30% of the people who have not caught H5N1 will catch the virus? This would mean 30% sick in the first wave, and 21% in the second, etc. I think it is the first meaning because I have read that it is expected that the attack rate will differ during each wave, peaking in the second.
So that would be good. It would mean that once it is over, and will be over at some point, 70% of the population never got sick and of those that did get sick 98% lived.
So yeah, if I was a urinator and I believed the CDC scenario was as bad as it could get I would not be as worried. But I am a dialyzor and I believe that if a CDC scenario pandemic hit today (and there is some small chance it could) it would not matter if you caught the flu or not. The pandemic would be 100% lethal if you need incenter dialysis to live.
I seem to be the only one pointing this out and I am around smart, knowledgeable people. People who are writing the papers, outlining the pandemic response plans that you can find on numerous government sites. I want someone to talk me off the ledge. I am waiting for a doc or a pandemic planning official to say “You are wrong. You have not considered this.” Instead I seem to be talking people up on the ledge with me.
And that is good. We must talk about this, we very well may have time. Hell, it might not ever happen. However, current emergency dialysis plans are the wrong plans for a pandemic. In an emergency like an Earthquake or hurricane, if you are unable to operate half the units in the area or you only have half the capacity you need to serve the numbers of dialyzors needing dialysis, what do you do?
You cut everyone’s run and give a little dialysis to everyone, with the goal being that you are trying to maintain frequency. In a pandemic, if you were at half capacity e.g. staffing shortfalls, this would be a bad strategy. You need to conserve supplies, getting people - staff and dialyzors - to the unit is your biggest problem and not spreading the flu is a goal. The right strategy? Decrease frequency, increase treatment length. Eight hour runs two days a week would be better then cutting everyone’s time by 33%. Eleven hour runs 3 times in two weeks would be better then ctting everyone’s time by 50%. I think clinically and logistically, but certainly logistically.
I know. I am Scribner Dialysis Product guy but think about it and then tell me I’m wrong.
I need hope. I could not go on without hope. So what you ask is my vision? I say it should be our finest hour. Are you prepared to demand more services, resources so you can be kept alive? Or are you prepared to stand up, relieve staff and dialyze each other? Our staff will need to care for their families who may be sick, their kids who are home from school or yes, the wider community.
Of course some would stand with us but shouldn’t we home dialyzors be prepared to be the answer? Shouldn’t those dialyzors who are able bodied prepare to be the answer?
It most likely will not happen in the next two years but what would we want to have in place if it struck in 2009? In 2012?
The renal industry, the professional organizations, the partners and the coalitions must take this threat seriously and on its own terms. It is not like an earthquake or an ice storm as bad as those can be. We will need new thinking to do our best.
It is unlikely. Pandemic flu is unlikely today but there is a chance. How could we justify being so flat footed, if it were to hit today or in a year. The first step is admitting you have a problem. The first solution is to show leadership.
We need transparent planning, renal industry planning that is pandemic specific. And my answer is the dialyzors. The dialyzors are the solution, we are not the problem.
Unfortunately, bird flu jumping to humans is a predicted threat a lot like California falling into the Pacific after “the big one”. We all suspect it’s coming, but nobody really knows when, and some things seem too big to plan for. Worse, even when big things do happen with enough time to plan for them (oh, gee, I don’t know, like the dikes bursting in New Orleans because they weren’t built to withstand anything beyond a class 3 hurricane?!) we don’t do a great job.