The article by Dr. Richard Garden in the fall 2006 Correct Care (Volume 20 Issue 4) titled Pandemic Flu: Planning for the "What If" is an excellent overview of the concerns and issues that will face the correctional healthcare industry when pandemic flu strikes. In fact the only point on which I can disagree with Dr. Garden is in the title. It is not "if" but "when" the pandemic will occur. History over the last three centuries has taught us that novel avian pandemic flu occurs every 91 years (plus or minus 3.5 years for antigenic drift). Given that the last major pandemic was the 1917/1918 Spanish flu this means that we can expect a pandemic flu outbreak between 2006 and 2013.

It is a mathematical certainty.

I must compliment Dr. Garden on being the only other physician that I have heard discussing the impact on the healthcare workforce in accurate terms. He is absolutely correct that up to 50 percent of the workforce may not report to duty. The reasons are well demonstrated in the history of pandemics.

The true impact of this disease lies in the numbers. In 1918 100 percent of the entire world was exposed to what would later be called the Spanish Flu. This new strain of avian flu had never been encountered before by a human population, and as a result, there was no immunity to this particular strain. Of that world population, one third would ultimately fall ill, in fact, 50 to 80 percent of the youngest, healthiest, and strongest would fall ill when future generations would divide out the victims.

Of those that fell ill, half ultimately required some assisted care. They were placed in infirmaries or makeshift hospitals in warehouses, wharfs, and military barracks. In today's world, they would qualify for hospital care or home health nursing.

Of those hospitals and infirmaries, half suffer extreme respiratory difficulties as their lungs filled with fluid and blood, the result of their own bodies' counterattack on the viral invasion. Coughing and frothing at the mouth, occasionally spitting up blood, these individuals would have a disease that today's medical professionals call ARDS, Acute Respiratory Distress Syndrome. In the modern medical age, these patients would have a plastic tube placed into their lungs to assist their breathing and a ventilator would force air in and out of their lungs. Half of the ARDS patients 1918 died.

But it's not percentages, but real numbers that portend the severity of this disease. There are over 300 million people in the United States and over 6 billion worldwide.

One third of those will fall ill. One hundred million here at home and two billion across the planet.

Half of those individuals will qualify for hospitalization. Unfortunately, in a survey performed by the American Hospital Association in 2005, there are only 955,768 hospital beds in the United States, far short of the 50 million that would be needed. To make this situation work, at the peak of cold and flu season in 2005, only four percent of these hospital beds were available and unoccupied. That means that there will be fewer than 40,000 hospital beds available for this onslaught of 50 million patients.

Of the 50 million patients who qualify for hospitalization, half or more will need ventilators. Dr. Michael Olsterholm in a New England Journal of Medicine article in 2004 found that there were only 105,000 ventilators in the United States. Of these, a high percentage were either already in use for chronic ventilator-dependent patients such as small children and spinal cord patients, or were out of service for cleaning and repair, leaving just over 16,000 ventilators available nationwide to help 25 million flu related ARDS victims breathe.

Of the 25 million with ADRS, with or without ventilator care, half would be expected to die. This 12.5 million people will pass away in waves as pandemic influenza spread over a span of only 12 to 18 months.

Now, admittedly, these are the most dire numbers. The pandemic flu could prove to be far less deadly, far less contagious. On the other hand, H5N1 has already proven to be a formidable foe with death rates initially greater than 70 percent and now still hovering around 50 percent.

The Centers for Disease Control (CDC) have given optimistic sounding percentages but as the old adage goes, the "devil is in the details". Let's look at the percentages and the details.

* One third of 100 percent is 33 percent.

-This is the "attack rate".
* Half of 33 percent is 16.5 percent.

-This is the number of people who qualify for hospitalization, but the CDC knows that in the event of a pandemic, only the most sick will actually be placed in the hospital. Clearly the most sick will be those with ARDS.
* Half of 16.5 percent is 8.25 percent.

-These are the sickest of the sick, those with ARDS. Rounded off, this is 8 percent, the number that the CDC says to expect for hospitalization.
* Half of 8 percent is 4 percent.

-This is the expected death rate predicted by the CDC.

The "devil in the details" is that these percentages are based on "the total population." Physicians, medical planners, and other pundits usually discuss percentages based on "those with the flu". We are not talking about "those with the flu" we are talking about a number three times that size.

When these ominous numbers were scrutinized further, a far more dire picture evolved. Research into the 1918 pandemic, as well as pandemics before and since 1918, have shown that the majority of illness and death occurred not in the very old or the very young, not in the sick and infirm, but in those who are in the "prime of life"; those age 18 to 40.

But there is a bigger problem for Correctional Medicine.
Because of the way that novel avian viruses (pandemics) attack the lungs and cause "immune system storms", the ultimate irony of a pandemic is that the younger and stronger you are the more likely you are to die. In 1918 fully two-thirds of all those who became ill were in the age range of 18 to 40. More distressing is the fact that 98 percent of all of those who died were age 18 to 40 years. In fact, those over age 55 had no greater rate of illness or death during the pandemic of 1918 than they did in any other flu season in the years immediately before or after that great pandemic. Similarly, those less than 18 years of age suffered no increase in death rate.

The implications for America's correctional institutions are inescapable. Fully two-thirds of the active workforce will fall ill during the 16 to 18 months of the disease throughout the pandemic. Twenty-five percent of the young workforce (the 18 to 40 years) will die in that 18 months. Who will replace them?

Dr. Garden is also correct that correctional institutions as well as the disabled and children have not been considered in local, regional or state pandemic planning. In fact they are barely mentioned even in federal planning. As Dr. Garden points out it will be up to the correctional institutions and specifically correctional healthcare to contact State Homeland Security representatives as well as federal agencies and become part of the plan.

In June of 2006 the Institute of Medicine published reports on the state of preparedness but pointed out that even emergency services had been left out of much planning. Even the Institute of Medicine did not mention the fact that institutional medicine including correctional healthcare are not even mentioned in these plans.

It is imperative that healthcare professionals of all stripes become expert not only in pandemic planning but in the "All Hazards" approach to disaster and catastrophic event planning. Whether it is a pandemic, a hurricane, an earthquake, a forest fire, or a terrorist event that threatens the community in which a correctional institution exists, bitter experience has taught us that concentrations of individuals living in institutional settings whether in prisons, military barracks or university dormitories become the "cave canaries" of society.

In 1918 Spanish flu outbreaks, which actually began in Kansas, were first seen in epidemic form in U.S. military barracks. The outbreaks of measles in the 1980s were first seen in university dormitories across the United States. And the largest concentrations of the recurrence of tuberculosis, as we all know, is seen in correctional institutions.

In the same issue (Volume 20 Issue 4), Dr. Scott Savage reviews medications that he believes every institution should have for pandemic flu planning. His insightful article disclosed that Dr. Savage is not only a skilled director and physician but has a great understanding of the all hazards approach.

While writing his article specifically for pandemic flu planning with a title that would suggest a review of antiviral medications, Dr. Savage correctly links pandemic flu planning for the greater need for overall disaster planning based on mechanism of injury. In short, Dr. Scott Savage is introducing an "All Hazards" approach to disaster planning in the correctional healthcare industry.

As Dr. Savage clearly knows, disaster is when needs exceed resources and his article provides a basic list of resources that will help stave off disaster in a correctional healthcare institution. His list of medications covers the waterfront for first responders and the all critical 72 hours of a disaster.

Whether it is Dr. Savage's extensive military training or his experience in disaster medicine, Dr. Savage's article displays and understanding of the fact that like all aspects of healthcare, corrections medicine must not only plan for a pandemic but for all 14 mechanisms of injury in the case of an adverse event with the intention of preventing that adversity from becoming a full fledged disaster.

Resilience is when you have sufficient resources to prevent needs from exceeding those resources. By following Dr. Savage's advice, corrections healthcare professionals will take a giant leap towards resilience.

Dr. Garden, Dr. Savage and the editorial staff of Correct Care are to be complimented for publishing some of the few articles to consider planning for the impact of the coming pandemic not only on our patients but on our colleagues and our society.

Kudos!