Optimal outcomes will depend on close collaboration between family physicians and public health officials. Is your practice ready?
Fam Pract Manag. 2007 Mar;14(3):11-12.
Whether or not the avian influenza strain H5N1 evolves to become the cause of the next world-wide influenza pandemic, such a pandemic will ultimately occur. When it does, it will challenge the ability of medical and public health systems worldwide to care for the sick and control the epidemic. In the United States, up to 30 percent of the population is likely to be infected, and half of these will seek medical care. There could be between 200,000 and 2 million deaths depending on the virulence of the organism.1
To minimize the effects of seasonal influenza, we rely on annual vaccine and antiviral therapy and prophylaxis. When a novel, pandemic strain occurs, only a small supply of vaccine, if any, is likely to be available, and once vaccine production begins it will be at a rate that will allow immunization of only a small proportion of the population each week. Currently available antiviral drugs may or may not be effective. Infection control practices may well be our main tool to control the epidemic.
In the United States we do not have a strong public health system. Our local and state public health departments are underfunded and understaffed. Our public health and medical systems are not well coordinated; physicians and public health departments do not have a history of communication or collaboration. In an ideal world, family physicians would be the foundation of our nation's public health system and there would be cooperation and a close connection between us and the public health infrastructure. Given that this is all too often not the case, what can each of us do, on an individual level, to make the situation better?
First, we can ensure that our offices and clinics do not become major sources of the spread of infectious diseases. Office infection control, including the enforcement of respiratory hygiene in our waiting areas, should be practiced routinely.2 Potentially infectious patients frequently sit in a clinic or emergency department waiting area exposing many others to a contagious organism that is spread by coughing and sneezing. This simply should not occur.
Medical staff should receive all recommended immunizations, and physicians should make a strong commitment to having their patients immunized as per current CDC recommendations. [For information on managing immunizations in the office, see “Vaccine Administration: Making the Process More Efficient in Your Practice,” page 48.] Current recommendations for adult, child and health care worker immunizations can be found on the CDC Web site (see http://www.cdc.gov/nip/recs/adult-schedule.htm and http://www.cdc.gov/ncidod/dhqp/wrkr_immune.html).
Family physicians should be aware of national and local infectious disease outbreaks and know the signs and symptoms that would lead us to suspect a particular patient might be a “case” (weekly updates on influenza can be found at http://www.cdc.gov/flu/weekly). If we do not know what laboratory tests are recommended to confirm a case, we should know who to call at the local public health department to find out. This is also true for treatment and prophylaxis recommendations as well as community measures such as restriction of activities, isolation and quarantine. For state-specific public health contact information, see http://www.cdc.gov/mmwr/international/relres.html or http://www.statepublichealth.org/index.php?template=directory.php.
In an influenza pandemic, physician communication with the local public health department will be especially important because both vaccine and chemoprophylaxis drugs will likely be in short supply and it will be critical that they are reserved for high priority groups.1,3 Health care workers with direct patient contact will be in the highest priority tier. Individual physicians will face patient expectations and demands that will at times be inconsistent with these priorities. Having the public health department set the guidelines and priorities will strengthen physicians' hands with patients. In some instances, the public health department may control the access to supplies of vaccines and drugs. Conversely, public health recommendations cannot be fully implemented without the cooperation of local physicians.
The performance of public health departments and physicians and the degree of collaboration between “us” and “them” will significantly affect the outcome of the pandemic. The best outcomes will occur where family physicians are aware of an impending outbreak, have implemented strict infection control practices in their clinics, have insisted that their staff are optimally immunized, call the health department to report suspected cases, collect recommended laboratory specimens to confirm or rule out cases, rapidly implement treatment and prevention recommendations and help the public health department limit the spread of infection.4 Anything short of this and we will not have fulfilled our role.
Family physicians and public health officials each should recognize, respect and enhance the other's role at all times, especially in a public health emergency. If we communicate and collaborate, our communities will benefit.
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About the Author
Dr. Campos-Outcalt is clinical sciences analyst in the AAFP Scientific Activities Division and associate chair of the Department of Family and Community Medicine, University of Arizona College of Medicine, Phoenix. Author disclosure: He discloses that he is a member of the Rush Medical College Influenza Speakers Bureau.
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1. United States Department of Health and Human Services. HHS pandemic influenza plan. 2005. Available at http://www.hhs.gov/pandemicflu/plan/. Accessed Feb. 22, 2007.
2. Campos-Outcalt D. Infection control in the outpatient setting. J Fam Pract. 2004;53:485–487.
3. Temte JL. Preparing for an influenza pandemic: vaccine prioritization. Fam Pract Manag. 2006;13(1):32–34.
4. Campos-Outcalt D. Pandemic influenza: How it would progress and what it would require of you. J Fam Pract. 2005;54:1045–1048.
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