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ICG Risk Blog - [ Federal pandemic influenza plan can only count on half the expected public health staff to show up for a pandemic ]

Federal pandemic influenza plan can only count on half the expected public health staff to show up for a pandemic

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[Most of the] public health workers who would serve as a backbone of locally-driven emergency response in an influenza pandemic setting [feel] they will work under significant personal risk, in a scenario they are not adequately knowledgeable about, performing a role they are not sufficiently trained for, and believing this role does not have a significant impact on the agency’s overall response.

The "perceived risk associated with the worker’s role in an influenza pandemic" is sufficiently great that without specific intervention programs tailored for these workers, nearly "half of local public health workers would be unlikely to report during an extreme crisis. Three out of four technical and support workers don’t even think they will be asked to report to work during a pandemic."

I like to say that, "Any plan conceived and approved by or under sitting politicians must, by definition, be adjudged a success or it will be rerun until it does." Having written on previous TOPOFF (Top Officials) exercises here in the US, whose tests are gerrymandered in their instructions and boundary conditions so as to insure success, I am forever credulous of the accuracy of these tests to mimic reality. Each time the real world rudely intrudes, in the likes of Hurricane Katrina, our planning and recovery process is shown to be inept. (An example is the failure to resolve unintelligible communications channels across disciplines (such as between fire and police) that was known before 11 September, 2001, but was still not redressed as of Katrina.) See:

None of the TOPOFF exercises assumed a degradation of public health workers any where near the results of a study from the Johns Hopkins Bloomberg School of Public Health, Local public health workers' perceptions toward responding to an influenza pandemic.

The HHS Pandemic Influenza Plan clearly states the impact of an Avian Flu Influenza accurately enough:

When a pandemic virus strain emerges, 25% to 35% of the population could develop clinical disease, and a substantial fraction of these individuals could die. The direct and indirect health costs alone (not including disruptions in trade and other costs to business and industry) have been estimated to approach $181 billion for a moderate pandemic (similar to those in 1957 and 1968) with no interventions. Faced with such a threat, the U.S. and its international partners will need to respond quickly and forcefully to reduce the scope and magnitude of the potentially catastrophic consequences.

The HHS plan describes a "critical role for local and state public health agencies during a pandemic, including: providing regular situational updates for providers; providing guidance on infection control measures for healthcare and non-healthcare settings; conducting or facilitating testing and investigation of pandemic influenza cases; and investigating and reporting special pandemic situations."

Among those roles are, for example, key Healthcare and Emergency Response capabilities "Needed for Implementation of an effective response":

  1. Equipment and supplies maintained in the Strategic National Stockpile and state stockpiles sufficient to enhance medical surge capacity.
  2. Federal Medical Stations and healthcare assets (people, facilities, equipment, supplies, and exercised procedures) to enhance medical surge capacity.
  3. Widely available accurate rapid diagnostic methods to detect and characterize influenza viruses.
  4. Assets (people, facilities, equipment, supplies, and exercised procedures) for the timely, safe, and respectful disposition of the deceased.
  5. Institutionalization of psychosocial support services and development of workforce resiliency programs.

The term "Assets (people, facilities, equipment, supplies, and exercised procedures)" appears in other subsections of the HHS document, but no mention is made of the option that the local healthcare backbone will not show up for work - and no federal plan can persevere without the backbone of local support.

No one had apparently thought to query the local health staff, divided between professionals (all physicians, nurses and public health professionals) and technical/support staff on the following issues:

  • Probability of reporting to work
  • Possibility of being asked by their health department to respond to an emergency
  • Degree of knowledge "about the potential public health impact of pandemic influenza"
  • Confidence of safety "in their work roles"
  • Likelihood of family preparation "to function in their absence"
  • Likelihood they would get timely updates from their health department
  • Familiarity with "their role specific response requirements"
  • Ability to "address the questions of a concerned member of the public"
  • Significance of their role "in the agency’s overall response"
  • Importance of "pre-event preparation and training"
  • Importance of having "psychological support available during the event"
  • Importance of having "psychological support available after the event"

Risk perception theory (see other links below) describes a risk horizon in which "the summation of actual risk and other peripheral influences independent of the actual risk, such as perceived authority, trust, and situational control; these peripheral influences have been termed "outrage" or "dread." It should come as no surprise that actual risk is nestled within a group of contributing factors peripheral to the actual risk that "will have a considerable practical impact on how public health employees would respond in a crisis."

Employees' "sense of dread due to a lack of personal control" were caused by such variables as "uncertainty regarding working environment safety, unclear expectations of role-specific emergency response requirements, safety and well being of family members, inadequate emphasis on the critical value of each employee to the agency response efforts, and insufficient emphasis on stress management techniques."

The results were impressive:

  • 66% of public health workers "felt they would put themselves at risk of infection if they were to report to work during a pandemic"
  • Only 40% of all respondents felt it likely "they would be asked by their health department to respond to a pandemic influenza related emergency"
  • "Half of local public health workers would be unlikely to report during an extreme crisis"
  • "Three out of four technical and support workers don’t even think they will be asked to report to work during a pandemic"

These figures do not include those who cannot show up because of a primary or secondary interruption, i.e., they are prohibited due to such impacts as a gridlocking transport system.

So much for the ability of the US to carry out the HHS Pandemic Influenza Plan. Sustained, nationwide interventions with healthcare staff will be required to improve their willingness "in non-public health department settings to report to duty in disasters include workforce preparedness education, provision of appropriate personal protective equipment, crisis counseling, family preparedness and social support."

Local public health workers' perceptions toward responding to an influenza pandemic
By Ran D. Balicer, Saad B. Omer, Daniel J. Barnett and George S. Everly Jr.
BMC Public Health 2006, 6:99 doi:10.1186/1471-2458-6-99
ISSN 1471-2458
Publication date 18 April 2006
Full text PDF
Abstract

Nearly Half of Public Health Employees Unlikely to Work During Pandemic
Public Health News Center
Johns Hopkins Bloomberg School of Public Health
April 17, 2006

HHS Pandemic Influenza Plan
U.S. Department of Health and Human Services
November 2005

Applying risk perception theory to public health workforce preparedness training
By Barnett DJ, Balicer RD, Blodgett DW, Everly GS Jr, Omer SB, Parker CL, Links JM.
Johns Hopkins Center for Public Health Preparedness, Johns Hopkins Bloomberg School of Public Health
Journal of Public Health Management & Practice, Suppl:S33-7
November 2005

Explaining risk perception. An evaluation of the psychometric paradigm in risk perception research
Lennart Sjöberg, Bjørg-Elin Moen, Torbjørn Rundmo
Editor: Torbjørn Rundmo
Norwegian University of Science and Technology, Department of Psychology
ISBN 82-7892-024-9
Trondheim, September 2004

SARS Risk Perception, Knowledge, Precautions, and Information Sources, the Netherlands
Johannes Brug, Arja R. Aro, Anke Oenema, Onno de Zwart, Jan Hendrik Richardus, and George D. Bishop
Emerging Infectious Diseases

Vol. 10, No. 8, August 2004

Explaining risk perception. An evaluation of cultural theory
Sigve Oltedal, Bjørg-Elin Moen, Hroar Klempe, Torbjørn Rundmo
Editor: Torbjørn Rundmo
Norwegian University of Science and Technology, Department of Psychology
ISBN 82-7892-025-7
Trondheim, April 20, 2004

A Social Network Contagion Theory of Risk Perception
Clifford W. Scherer and Hichang Cho
Risk Analysis
doi:10.1111/1539-6924.00306
Volume 23 Issue 2, Page 261 - April 2003

Risk perception: Theories and models
Anna-Mari Aalto, Pilvikki Absetz, Yael Benyamini, Pepijn van Empelen, David French, Peter Harris, Britta Renner, Fritz Strack
European Health Psychology Society
2003

Gordon Housworth



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