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

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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

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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.

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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.

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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.

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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
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CDC POTUS Report Influenza Week 38 2 OCT
2009Cumulative Lab-Confirmed Syndromic Deaths
by Age Group National Aggregate Reporting of
Influenza (n1,379)
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California Sentinel Providers Influenza-Like
Visits, 2004-2009.
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Novel H1N1 Confirmed and Probable Case Rate in
the United States, By Age Group July 24, 2009
http//www.cdc.gov/h1n1flu/surveillanceqa.htm
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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
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Hospitalized and fatal cases pandemic (H1N1) 2009
in California, 4-9/2009(CDPH Surveillance data)
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USA 2000-2008Seasonal 2009 H1N1 Influenza
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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.

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International Co-circulation of 2009 H1N1 and
Seasonal Influenza http//www.cdc.gov/h1n1flu/upda
tes/international/map.htm
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WHO Pandemic Phaseshttp//www.searo.who.int/EN/Se
ction10/Section2562.htm
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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
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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.

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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

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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.

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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

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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.

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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.

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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).

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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.

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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

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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.

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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

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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

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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

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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

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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.

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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.

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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.