At the turn of the 19th century, miners carried canaries into the caves not as pets, but as sentinels. The canary’s song was an angelic chorus to reassure the miners of their safety. It was not a klaxon alarm, but the silence of death that warned of toxic air. The term “cave canary” has become synonymous with the death of innocents heralding the death of all.
New Headlines – Not New News
Like so many of the miscalculations of the early pandemic preparation, many believed that the first to fall in the coming pandemic would be children and the elderly. Seasonal influenza affects these age groups more than those in the midst of life because immune function flags at the extremes of age. Conversely, pandemic influenza wreaks its havoc by over-activating the immune system.
Nursing homes, correctional institutions as well as the disabled and children have not been considered in local, regional, or state pandemic planning. In fact, they are barely mentioned even in federal planning. In June of 2006 the Institute of Medicine published reports on the state of preparedness but pointed out that even emergency services had been left out of much planning.
It is imperative that healthcare professionals of all stripes become experts not only in pandemic planning but in the “All Hazards” approach to disaster and catastrophic event planning. Whether it is a pandemic, a hurricane, an earthquake, a forest fire, or a terrorist event that threatens the community, bitter experience has taught us that concentrations of individuals living in institutional settings, in prisons, military barracks, or university dormitories become the “cave canaries” of society.
In 1918 Spanish flu outbreaks, which actually began in Kansas, were first seen in epidemic form in U.S. military barracks. The outbreaks of measles in the 1980s were first seen in university dormitories across the United States. And the largest concentration of the recurrence of tuberculosis is seen in correctional institutions.
The 2003 SARS outbreak also provided us with a small-scale example of the effects of a pandemic on healthcare. Following the outbreak of SARS in Canada, healthcare workers in 4 Toronto area hospitals began to fall ill. Soon nurses and doctors were looking through protective equipment at colleagues and friends. The disease had changed the normal “us and them” relationship to “us and me.” These professionals watched their friends die. The result of SARS on the healthcare professionals who worked in these 4 Toronto hospitals was that 50% left healthcare entirely.
It is a Mathematical Certainty
The most ominous words ever uttered by a disaster preparedness expert were voiced during a deep background interview. This expert stated simply that given the current state of hospital preparedness and the current rate at which facilities are becoming disaster ready, there will be no meaningful level of preparedness in this decade unless someone blows up a hospital. This may seem a bit extreme, but declassified documents show that Al Qaeda seeks to steal an ambulance and blow it up at a major American trauma center.
Unfortunately, this scenario is based on the lesser of the threats currently facing healthcare. History over the last three centuries has taught us that novel avian pandemic flu occurs every 91 years (plus or minus 3.5 years for antigenic drift). Given that the last major pandemic was the 1917/1918 Spanish flu this means that we can expect a pandemic flu outbreak between 2006 and 2013.
The true impact of this disease lies in the numbers. In 1918 100 percent of the entire world was exposed to what would later be called the Spanish Flu. This new strain of avian flu had never been encountered before by a human population, and as a result, there was no immunity to this particular strain. Of that world population, one-third would ultimately fall ill, in fact, 50 to 80 percent of the youngest, healthiest, and strongest would fall ill when future generations would divide out the victims.
When these ominous numbers were scrutinized further, a far more dire picture evolved. Research into the 1918 pandemic, as well as pandemics before and since 1918, has shown that the majority of illness and death occurred not in the very old or the very young, not in the sick and infirm, but in those who are in the “prime of life”; those age 18 to 40.
Because of the way that novel avian viruses (pandemics) attack the lungs and cause “immune system storms”, the ultimate irony of a pandemic is that the younger and stronger you are the more likely you are to die. In 1918 fully two-thirds of all those who became ill were in the age range of 18 to 40. More distressing is the fact that 98 percent of all those who died were aged 18 to 40 years. In fact, those over age 55 had no greater rate of illness or death during the pandemic of 1918 than they did in any other flu season in the years immediately before or after that great pandemic. Similarly, those less than 18 years of age suffered no increase in death rate.
Nightingales: The Modern Cave Canaries
Like the cave canaries of old, the biological sentries for pandemic influenza will be those most exposed and most sensitive to the disease. The modern cave canaries will be healthcare professionals. The spectrum of patients to which each healthcare provider is exposed combined with the fact that healthcare providers are typically in the prime age for pandemic infection means that the healthcare workforce is the ideal high-fidelity influenza biosensor. When pandemic influenza enters a community it will be these most valuable members of the pandemic response who will fall first.
In the early days of the AIDS epidemic, it was not society’s nightingales who suffered first, but those who were shunned by society. The deaths of homosexual men foretold not only of the epidemic at hand, but of a far more ominous trend. Human Immunodeficiency Virus (HIV) initially spread slowly through a subset of the gay male community while another, generally more sexually active subset remained largely uninfected. Despite frequent sexual encounters with multiple anonymous partners, gay male bathhouses functioned as relatively closed micro-communities that occasionally exchanged diseases, but were initially AID free. Suddenly HIV was introduced into the bathhouse scene and exploded in a manner not previously seen in any disease.
The combination of the closed bathhouse community and the high level of infection exchange through sexual activity created an environment, not unlike a laboratory bioreactor accelerating the rate of viral replication and viral mutation. Because this bioreactor-type environment required both a behavioral pattern conducive to disease exchange and an infectious disease prone to mutation to combine in a discrete location, the bath houses were termed Behavioral Amplification and Transmission Sites (BATS).
BATS and Bird Flu
Unfortunately, unlike the miner’s canaries, healthcare’s nightingales are a migratory flock. In addition to their primary jobs in community healthcare facilities, offices, hospitals, and ERs, healthcare providers and nurses in particular moonlight as part-time staff in any number of roles including correctional institution healthcare. America’s jails and prisons, like the bathhouses of the 1980s, provide a modern bioreactor for tuberculosis, HIV, AIDS, and soon, pandemic influenza.
A worrisome scenario envisions the arrival of a low-level pandemic influenza infection concentrating in the healthcare workforce. As this workforce migrates from their primary job to secondary work sites, they become vectors for the spread of the disease. The disease in introduced into the closed environment of the correctional institution where close living quarters, poor hygiene, and sexual practices increase the spread of disease as well as the reinfection rate. Prisons become BATS for pandemic influenza and mutation rates accelerate exponentially.
The same workforce that introduced the original infection is cross infected with the new mutated strain and is vector spread back to the general community. Worst of all, the nature of influenza mutation and virulence supports the proposition that BATS will select preferentially for the most infectious and lethal new strains.
The implications for America’s hospitals and healthcare institutions are inescapable. Fully two-thirds of the active workforce will fall ill during the 16 to 18 months of the disease throughout the pandemic. Up to fifty percent of the workforce will not report to duty as they care for themselves and their family. As healthcare workers migrate from job to job, they carry the disease into BATS and ultimately carry back more lethal forms of the disease. Twenty-five percent of the young workforce (the 18 to 40 years) will die.
The ultimate impact of the pandemic on healthcare:
- During the pandemic outbreak, up to 50% healthcare workforce absenteeism
- During the pandemic outbreak, up to 25% healthcare professionals death rate
- Following the pandemic outbreak, 75% of healthcare professionals still alive
- Following the pandemic outbreak, 50% of remaining healthcare workforce quits
- Over the course of the pandemic outbreak, the healthcare workforce shrinks 62.5%
Who will replace them?
Lest healthcare embrace preparedness this is the fate of us all.