Pandemic Home Care Options
# 258
The word, whispered sotto voce in the medical community, is that if an H5N1 bird flu pandemic comes, most people will have to be cared for in their homes. Hospitals, and ad hoc flu clinics could in no way begin to care for the anticipated tens of millions of simultaneous avian flu victims. While vague references to the `sickest of the sick’ being admitted to hospitals have been made, it isn’t clear whether even that would be possible.
The numbers in a pandemic are staggering.
The base assumption is that a pandemic would have an attack rate of roughly 30%. That is; 30% of the country, and of the world, would contract the virus. There are many who question that number, feeling that it is low. I tend to agree, but for the sake of uniformity, we’ll use that number.
In the United States that means that 90 million people could be stricken. In the UK, 20 million. And worldwide, 2 billion people would be hit by the virus.
Now, not everyone will be sickened at exactly the same time. There will be a run up to the peak number of infections, and then a tapering off. There may be several waves, as we saw in 1918. But it is probably safe to assume that at its worst; between 5% and 10% of the worlds population may be sick at the same time.
So, let’s adjust our numbers. In the US, that means between 15 and 30 million sick at one time, in the UK, between 3 and 6 million. Worldwide, between 300 and 600 million.
In the United States we have but 1 million hospital beds, of which 90% are occupied at any given time. In the UK, just under 200,000 beds, with a similar occupancy rate. Even if it were possible to discharge all non-flu patients (and it isn’t), there would still be between 15 and 30 patients vying for each bed.
Adding to the problem will be the loss of hospital workers due to the virus, with an expected absenteeism rate of up to 40%. Again, possibly a low estimate. If 5% of flu victims see the inside of a hospital, it would be a miracle.
As hoc flu clinics, set up in converted auditoriums and high schools could take up some of the slack, but are unlikely to make much of a dent. These facilities would need personnel and provisions, both of which will be in short supply.
The bottom line is, if you or a family member contracts the avian flu, you will probably have to ride out the illness at home, under the care of your immediate family. Given the numbers, there really isn’t much choice. How those who are homeless, or who have no family to care for them will fare, has not been adequately addressed.
Were the H5N1 virus an ordinary flu virus, home care might not be as great an issue.
After all, millions of people get the flu every year and most manage to recover at home without the intervention of a doctor or the need for hospitalization. But the H5N1 virus is a novel virus; one that humans have little or no immunity to, and it has thus far exacted a heavy toll on those infected. Most developed pneumonia, some saw the infection spread to other organs like the liver, kidneys, and brain, and fully 60% of those infected, have died.
Instead of running its course in 5 to 7 days, like a seasonal flu, most H5N1 survivors have required 30 days or more of convalescence.
Caring for avian flu patients in the home is therefore likely to be more involved, and more intensive than handing them a bottle of Nyquil, a box of tissues, and the TV remote.
To date, most H5N1 virus sufferers have been treated aggressively with IV’s, Oxygen, antivirals (Tamiflu), antibiotics, and many have been placed on ventilators. While many of these interventions are unlikely to be available in a home setting, trying to keep a severely ill patient hydrated, clean, and comfortable is a full time job.
Complicating matters, influenza viruses are notoriously communicable, and while the H5N1 virus has yet to acquire that trait, by definition, if it becomes a pandemic strain, it will be highly contagious. Which means that every member of a household with an infected patient will be at risk.
The argument has been made, and may well have merit, that as a flu victim may be contagious for up to 48 hours before showing symptoms, all family members would already be exposed. If they were going to develop the disease, that die was already cast.
There are, however, unanswered questions regarding viral loading, length of exposure, and routes of transmission and we simply don’t know how much contact it will take to convey the virus from one person to another. Initial exposure doesn’t necessarily equate to infection.
In a hospital setting, Health Care Workers (HCW’s) would understandably demand that they be provided suitable PPE’s (Personal Protective Equipment) such as gloves, N95 masks, gowns, and goggles. The contagiousness of the disease, along with the morbidity and mortality rates, makes treating patients without them an unacceptable risk. Those risks do not diminish simply because one is in a home environment.
Obviously, infection control is going to be an issue when treating avian flu patients in the home, and a failure to deal with that will likely spread the disease throughout the entire household. Given the duration of the illness, and the incubation time once exposed, an entire family could be sickened at the same time, with no one available to care for them.
While home care may be the only option open to us, it has some serious, and potentially deadly limitations. Fortunately, there are things we can do to lower those risks.
First, you need to create a plan as to what you will do if you suspect a family member has contracted the flu.
Some of this plan will be contingent upon what services are available to you and your family during a pandemic, and that will vary depending upon your location, the severity of the crisis, and how early or late in the crisis your needs arise.
In some localities there are plans to provide telephone call-centers, other places may provide home delivery of certain meds and supplies, and a few places may even manage some sort of home visits by medical teams. Even so, the burden of round the clock care will fall on families.
Early detection of any illness in the family will be important. All family members should be instructed to `fess up’ immediately if they suspect they may be falling ill. Suspected avian flu patients should be separated from the rest of the family as quickly as possible, to limit cross contamination.
Setting up a sick room, and maintaining as good of isolation practices as possible, may help reduce this risk. Having latex gloves on hand, N95 masks, and disposable gowns may help protect the caregiver. Frequent hand washing, and the use of alcohol gel sanitizers, is another sensible precaution. You obviously want to avoid infecting the caregiver and avoid having them spread the disease throughout the house to others.
Along those lines, I’ve designed an experimental, and completely theoretical home isolation unit. The plans can be found in the library section of PlanForPandemic. It can be found at:
http://tinyurl.com/y29xss
Proper cleaning and disinfection supplies are a high priority. A 10% Clorox/water solution, or a 3% Lysol spray have both been recommended for infection control. Bagging infected or soiled linens or clothes prior to laundering them is a wise precaution.
Obviously, having adequate supplies of over-the-counter (OTC) medications such as Tylenol, Ibuprofen, expectorants, and oral rehydration solutions are a must.
Dr. Grattan Woodson’s guides to the home care of Avian Flu victims, available for free download from his website, are as good an overview of home care that I’ve found. If you don’t already have it, get it. Read it now, before you need to utilize the knowledge. That way, you’ll know what supplies you will need, and can acquire them now.
And while you are at it, Dr. Woodson’s book is an excellent overview of the avian flu threat. I highly recommend it to my readers.
And lastly, I would submit one more idea for my readers’ consideration. It will not suit every situation, and in fact, may only be of value to a small number of you. But during a crisis, such as a pandemic, bold ideas are often needed. Even if they are a bit unconventional.
I’ve discussed the difficulties of home care. The risks of spreading the infection throughout the household and the labor-intensive nature of caring for an avian flu victim are both good reasons to try another approach.
A neighborhood volunteer flu center. Manned by family members from your neighborhood, and setup in a single house or apartment. Given the likely attack rate, you'd probably need one home or apartment for every 100 to 150 people in your neighborhood.
Rather than it being every household for themselves, with most of them being overwhelmed by the task of caring for one or possibly more victims, select one house on your block, or one apartment in your complex, and designate it as a flu care center.
You could then move suspected flu patients (with their permission) to this house and allow volunteers from their families to provide round the clock care.
There are a number of advantages to this neighborhood approach.
Instead of being forced to care for a family member 24 hours a day, 7 days a week, perhaps for weeks without a break, by combining forces with your neighbors, individuals might actually be able to take a break. Work 12-hour shifts. While it might seem riskier to volunteer to care for multiple patients than to care for one person in your household, the risks are likely far less.
You immediately reduce the chances of the virus spreading amongst your family members, thereby decreasing your chances of contracting it. You share the workload with others, and enable yourself the luxury of taking a break, and getting needed rest. This will help keep your immune system in better shape, and with rest, you are more likely to observe common sense infection control procedures and less likely to make stupid mistakes.
If a visiting doctor, or a nurse, or an EMT is available, even part time, then they only have to visit one site to see multiple patients.
Infection control will be easier in one location rather than in many houses at the same time. PPE’s supplies would be stretched, as one caregiver could oversee multiple patients.
And you may be able to rely on someone more dispassionate than you to care for a loved one during a medical crisis.
For it to work, you and your neighbors will have to work in concert. You will have to accept the idea that, by working together, you all have a better chance of getting through a crisis. And that means; everyone contributes.
Meals for patients and caregivers could be cooked offsite and delivered. Laundry could be done by volunteers in adjacent homes. Other volunteers could help bring in needed supplies. Not everyone would have to deal directly with infected patients, but it would have to be a community effort.
Obviously, a suitable location would be needed. And that would likely require someone giving up their home for the duration (or remaining on site to assist). It is possible that arrangements could be made to use a vacant house or apartment, but in either event, you will need to find a place where flu patients can be sequestered and cared for.
While seemingly ambitious, this idea would work in a lot of places. It eliminates some of the difficulties of the home care option that we will be saddled with. But, in order to work, it would require planning and cooperation between neighbors. It would also require a commitment from the entire neighborhood: a sharing of the risk, and of the work.
Yes, it’s a lot to ask.
But a pandemic, by its very nature, will ask a lot of each and every one of us.
