Page 44
New technologies—for example, those making use of location data or push notifications from mobile phones—could conceivably be leveraged to extend the utility of contact tracing for highly transmissible events, though this should be considered an open research question at this point. Absent widespread availability and effectiveness of such technologies, in the event of a large-scale respiratory outbreak, other nonpharmaceutical interventions (detailed below) may be more practical, though they are likely to be less effective. Health Systems and Infrastructure, Health Services, and Clinical Management Widespread transmission of a high-impact respiratory pathogen would cause a surge of patients seeking care that would challenge even the most well-prepared health system. As a result, victims of a large-scale outbreak in settings with weak health systems would likely die at a higher rate than would be otherwise expected, due to lack of available modern medical care. Individuals who need to use the overburdened healthcare system for routine care during an outbreak would also likely suffer elevated morbidity and mortality, as available health resources are shifted to the emerging outbreak. As seen in Box 6, absolute mortality estimates for a high-impact respiratory pathogen are much greater today than they were in past decades, which highlights the strain that health systems would be under. Unprepared or under-resourced health systems could make matters worse by exacerbating disease transmission through nosocomial spread and the inability to promptly 45 Published plan or revised plan in 2010 onwards Published plan before 2009 No plan/no publicly available plan diagnose and render care. During the 2003 SARS epidemic, transmission in healthcare settings played a prominent role, accounting for 72% and 55% of presumed and confirmed cases in Toronto and Taiwan, respectively.93 During the 2013-2016 West Africa Ebola epidemic, healthcare workers were 21 to 32 times more likely than the general public to get infected with Ebola, which had a severe impact on the affected countries’ already-depleted healthcare workforce.94 The provision of routine medical care also suffered setbacks, with an estimated 50% reduction in access to healthcare services during the epidemic, including care for other infectious diseases such as HIV, tuberculosis, and malaria.95 The ongoing Ebola outbreak in the Democratic Republic of Congo (DRC) has also seen substantial nosocomial spread to healthcare workers, accounting for approximately 6% of all cases.96 International initiatives have aimed to improve health system preparedness and response for outbreaks and pandemics of respiratory diseases, focusing largely on influenza, but global preparedness for a high-impact respiratory pathogen event remains inadequate. One of the strategic objectives of the 2019-2030 WHO Global Influenza Strategy is to “strengthen pandemic preparedness and response for influenza,” and it includes numerous health system–related efforts, including national planning and exercises; building stockpiling capacities; procurement, deployment, and administration of vaccines, treatments, and supplies; and multisectoral collaboration.54 Not every country, however, has developed influenza preparedness plans. WHO reports that only 32 countries developed or revised plans after the 2009 H1N1 pandemic, and 99 countries still have no influenza plan that is publicly available (see Figure 3).71,97 Despite these initiatives, preparedness for high-impact respiratory disease outbreaks such as influenza remains dependent on political will and sustainable human and financial resources-, and, thus, varies from nation to nation. Figure 3: Global Map Identifying Countries with National Influenza Preparedness Plans *Data extracted from WHO Strategic Partnership Portal 46 Early in a pandemic, isolation of the sick will be critically important to limiting further spread, but most hospitals around the world have very limited isolation capacity, particularly for airborne pathogens, and likely only a fraction of what would be needed in a large outbreak. To adequately prepare for and respond to outbreaks of respiratory pathogens, health facilities would need to increase their capacity for large-scale isolation of patients with highly transmissible respiratory diseases. While a small number of facilities have dedicated units for the isolation of high-impact infectious disease patients (eg, high-level isolation units), this capacity is very limited, and all facilities need to plan for less resource-intensive yet effective isolation strategies to handle larger patient volume. These include converting regular patient care units into isolation units or cohorting patients who are similarly infected. Plans for just-in-time care or triage facilities (eg, tents or other alternative care facilities) could also provide additional space during emergencies. Once an epidemic is under way, healthcare workers would need to be able to rapidly identify those in need of isolation. Training and education would be required to ensure that frontline healthcare workers, particularly those staffing emergency departments, were fully aware of the emerging epidemic and capable of implementing travel, exposure risk, and symptom screening in order to identify and isolate suspected cases. Surge capacity planning is another key issue. A large influx of patients during a respiratory pandemic would require additional staff and supplies. Healthcare workers would need to be trained in appropriate infection prevention and control practices, including personal protective equipment (PPE) donning and doffing, and appropriate hand hygiene. The availability of essential basic supplies and equipment must also be included in global planning efforts. There is a severe maldistribution of medical supplies between countries and health systems around the world, and a dedicated effort is needed to determine how low- and middle-income countries would maintain access to critical supplies (eg, masks, respirators, gloves, gowns, IV fluid bags, medical gases) during a large-scale respiratory disease