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Attending to Ethical concerns during the 2009 Pandemic H1N1 Influenza (Swine Flu)

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Title: Attending to Ethical concerns during the 2009 Pandemic H1N1 Influenza (Swine Flu)


1
Attending to Ethical concerns during the 2009
Pandemic H1N1 Influenza (Swine Flu)
  • Harvey Kayman, MD MPH PHMO III
  • Senior Science Advisor
  • Emergency Preparedness and Response Branch
  • California Department of Public Health

2
Learning Objectives
  • Review Public Health ethical frameworks that may
    help officials articulate options to make
    decisions in the midst of crises.
  • Review data from the spring H1N1 outbreak.
  • Review triggers in health care systems that may
    raise ethical concerns during a pandemic.
  • Entertain questions for discussion.

3
In Public Health, there is a tension between
  • Individual rights and freedoms, on the one hand,
  • and the publics health and the common good, on
    the other.

4
Address the immediate and long-term effects of
decisions
  • Ethical decision-making in influenza pandemic
    planning will encompass resource allocation,
    triage, standards of care, workforce management,
    personal liberty restrictions, and other issues
    involved in disruptions in daily living.
  • Kinlaw, K. and Levine, R. (2007). Ethical
    Guidelines in Pandemic Influenza. Available at
    http//www.cdc.gov/od/science/phec/panFlu_Ethic_Gu
    idelines.pdf.

5
Issues to consider when making hard choices
during a pandemic Beauchamp, Tom L.
Childress, James F. Principles of Biomedical
Ethics, Oxford University Press. 2001
  • Duty
  • Consequences
  • Family relationships
  • Rights

Egypt Wipes Out Pigs, their champion garbage
consumers. Goats are not up to the task S.
Baldwin NYT 9 20, 2009
6
CDC POTUS Report Influenza Week 38 2 OCT
2009Cumulative Lab-Confirmed Syndromic Deaths
by Age Group National Aggregate Reporting of
Influenza (n1,379)
7
California Sentinel Providers Influenza-Like
Visits, 2004-2009.
8
Novel H1N1 Confirmed and Probable Case Rate in
the United States, By Age Group July 24, 2009
http//www.cdc.gov/h1n1flu/surveillanceqa.htm
9
Novel H1N1 U.S. Population, By Age Group
Hospitalization Rate per 100,000 and Death rate
July 24, 2009 http//www.cdc.gov/h1n1flu/surveill
anceqa.htm
10
Hospitalized and fatal cases pandemic (H1N1) 2009
in California, 4-9/2009(CDPH Surveillance data)
11
USA 2000-2008Seasonal 2009 H1N1 Influenza
12
HOW IS PANDEMIC FLU DIFFERENT THAN SEASONAL FLU?
  • A pandemic (from Greek, meaning of all the
    people) influenza is a new strain of the flu.
  • It is capable of sustained transmission among
    humans and, as a result, causes a global
    outbreak.
  • Because there is little natural immunity,
    pandemic influenza will affect significantly more
    people than seasonal flu.
  • There have been at least 10 recorded flu
    pandemics during the past 300 years.

13
International Co-circulation of 2009 H1N1 and
Seasonal Influenza http//www.cdc.gov/h1n1flu/upda
tes/international/map.htm
14
WHO Pandemic Phaseshttp//www.searo.who.int/EN/Se
ction10/Section2562.htm
15
2009 H1N1 Geographic Spread in the
Americashttp//new.paho.org/hq/images/stories/AD/
HSD/CD/Epidemic_Alert_and_Response/MAPS/week38/eng
/map1.jpg
16
How long can a sick person spread the flu to
others?
  • People infected with seasonal and novel H1N1 flu
    shed virus and may be able to infect others from
    1 day before getting sick to 5 to 7 days after.
  • This can be longer in some people, especially
    children and people with weakened immune systems
    and in people infected with novel H1N1 flu.

17
1 Take time to get vaccinated.http//www.cdc.gov
/h1n1flu/
  • A new vaccine against novel H1N1 is being
    produced and will be available in the coming
    months as an option for prevention of novel H1N1
    infection.
  • People at greatest risk for novel H1N1
    infection include children, pregnant women, and
    people with chronic health conditions like

18
2 Take everyday actions to stay healthy.
  • Cover your nose and mouth with a tissue when you
    cough or sneeze. Throw the tissue in the trash
    after you use it.

19
2 Wash your hands
  • Wash your hands often with soap and water,
    especially after you cough or sneeze.
    Alcohol-based hands cleaners are also effective.
  • Avoid touching your eyes, nose or mouth. Germs
    spread that way. Though the scientific evidence
    is not as extensive as that on hand washing and
    alcohol-based sanitizers, other hand sanitizers
    that do not contain alcohol may be useful for
    killing flu germs on hands in settings where
    alcohol-based products

20
3-Take flu antiviral drugs if recommended
  • If you get seasonal or novel H1N1 flu,
    antiviral drugs can treat the flu.
  • Antiviral drugs are prescription medicines
    (pills, liquid or an inhaled powder) that fight
    against the flu by keeping flu viruses from
    reproducing in your body.

21
Social distancing
  • Social distancing measures are designed to
    increase the space between people and decrease
    the frequency of contact among them
  • Dismissing classes in schools and other
    school-based activities closing childcare
    programs and reducing out-of-school social
    contacts among children and youth.

22
Non-pharmaceutical interventions or NPIs
  • Social distancing strategies may be used
    independently or in combination with
    pharmaceutical interventions.
  • Reducing contact between adults in the community
    and workplace (e.g., canceling large public
    gatherings, altering workplace environments and
    schedules, changing leave policies, altering
    conditions for public transportation).

23
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24
Paid time off
  • 25 of businesses do not offer paid sick leave,
  • 65 do not offer paid time off to care for sick
    family members
  • 79 do not offer paid leave to care for children
    home from school.
  • What about the management of personnel who are at
    increased risk for influenza complications (e.g.,
    pregnant women, immuno-compromised healthcare
    workers) by placing them on administrative leave
    or altering their work location.

25
Psychological First Aid and Counseling Skills
H\DCDC\Outbreak investigations\July to Dec 2009
activation\Presentations\Mental Health\Chapter 3
SAMSHA Psych First Aid.htm
  • Establishing Rapport
  • Active Listening
  • Psychological First Aid
  • Provide protection from harm, and assistance to a
    safe environment.
  • Ensure that survivors are warm/cool enough and
    are being given fluids and food.
  • Promote a sense of security through orienting and
    reassurance.
  • Connect survivors with family, friends, and loved
    ones.
  • Problem Solving
  • Identify current priority needs and problems and
    possible solutions
  • Assess functioning and coping
  • Evaluate available resources
  • Develop and implement a plan

26
Issues related to surge capacity
www.hhs.gov/pandemicflu/plan/sup3.htmlsurge)
  • Develop a primary plan and contingency plan to
    address supply shortages.
  • Address process to manage concerns when
    acquisition of regulated supplies through normal
    channels, and alternative channels fail.
  • Stockpile at least a week's supply of consumable
    resources.

27
Minimizing severe consequences for at-risk
populations At-Risk Populations and Pandemic
Influenza Planning Guidance for State,
Territorial, Tribal, and Local Health Departments
the Association of State and Territorial Health
Officials (ASTHO)
  • Factors that increase the risk of harm during an
    influenza pandemic include
  • A. Economic disadvantage (e.g., having too little
    money to stockpile supplies, or to stay home from
    work for even a short time)
  • B. Absence of a support network (e.g., children
    homeless travelers and the socially,
    culturally, or geographically isolated)
  • C. Trouble reading, speaking, or understanding
    English

28
Minimizing severe consequences for at-risk
populations At-Risk Populations and Pandemic
Influenza Planning Guidance for State,
Territorial, Tribal, and Local Health Departments
the Association of State and Territorial Health
Officials (ASTHO)
  • Factors that increase the risk of harm during an
    influenza pandemic include
  • D. Needing support to be independent in daily
    activities because of
  • a. Physical disability
  • b. Developmental disability
  • c. Mental illness or substance abuse/dependence
  • d. Difficulty seeing or hearing
  • e. Medical conditions

29
Foundational Principles-Medical Ethics and Public
Health Ethics
  • Autonomy
  • Beneficence
  • Non Maleficence
  • Justice
  • Personal Autonomy and the Common Good
  • Obligation versus Responsibilities
  • Authority and Decision Making
  • Fair Distribution of Benefits and Burdens

30
Resource Allocation Planning and in crisis.
  • Fair Distribution of Benefits and Burdens
  • Negative Rights and Entitlements
  • Population, sub-group and Individual rights
  • Citizen Expectations and Trust
  • JUSTICE
  • Procedural justice
  • Distributive justice
  • Retributive justice

31
Finding a Scapegoat When Epidemics Strike
http//www.nytimes.com/2009/09/01/health/01plague
.html
  • When disease strikes and humans suffer the need
    to understand why is very powerful.
  • And, unfortunately, identification of a scapegoat
    is sometimes inevitable.

32
Ethical issues to consider in an influenza
pandemic.
  • Ensure consistency in applying standards across
    people and time (treat like cases alike).
  • Decision-makers should be impartial and neutral.
  • Ensure that those affected by decisions have a
    voice in decision-making and agree in advance to
    the proposed process.
  • Kinlaw, K. and Levine, R. (2007). Ethical
    Guidelines in Pandemic Influenza. Available at
    http//www.cdc.gov/od/science/phec/panFlu_Ethic_Gu
    idelines.pdf.

33
Ethical issues to consider in an influenza
pandemic.
  • Treat those affected with dignity and respect.
  • Ensure that decisions are adequately reasoned and
    based on accurate information.
  • Limiting individual freedom may be appropriate if
    maintaining that freedom puts others at risk.
  • Adopt the least restrictive practices that will
    allow the common good to be protected.
  • Kinlaw, K. and Levine, R. (2007). Ethical
    Guidelines in Pandemic Influenza. Available at
    http//www.cdc.gov/od/science/phec/panFlu_Ethic_Gu
    idelines.pdf.
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