It's that time of year again, time to start blowing the dust off your pandemic flu plan. Finances, budget cuts, staffing losses and fundamental changes in the way fire and EMS operate are at the forefront of fire-leadership agendas. It is easy for emergency management, and specifically flu planning, to sink to a low priority and be overlooked. Fire-service leadership should take time out from daily operations and examine their pandemic plans. It is imperative that certain lessons from past pandemics be discussed, as the consequences from failures in government preparedness can be severe and ultimately violate the public trust.

Historically, the influenza pandemic of 1918 is referred to as the most devastating epidemic of all time. Known as the Spanish Flu or "La Grippe," it was a global disaster, killing more in one year than the bubonic plaque, aka "Black Death," did in four during the 14th century. This strain of flu, which was a variant of the avian H1N1, was different in that it affected the young, from ages 20 to 40. More than 28% of Americans were infected, including President Woodrow Wilson. The flu spread across the globe and was responsible for between 20 and 40 million deaths.

Flu pandemics have the same category 1-5 rating scale as hurricanes. Generally there are two waves of illness in such a pandemic, each wave lasting six to eight weeks. The key measurement in determining a pandemic's severity is an excessive mortality rate. The flu season usually starts in early November, frequently around the time the first cold snap happens. A severe pandemic would have an illness rate of 30% and could kill as many as 1.8 million Americans in a worst-case scenario.

The 30% of Americans who fall ill during a pandemic will include some of your staff. Consequently, you need to evaluate how the societal impacts of a pandemic will effect your department. With the strained budgets that afflict so many departments, few are going to spend on preparing for a possible pandemic when they can barely afford the cost of daily operations. A recommended trigger point for implementing a pandemic action plan assumes a death rate of 1.5% to 2% and an illness rate of 20% for adults and 40% for children.

If your department is like most agencies, you likely have trimmed your staff down to a bare minimum. A run of flu through your staff easily could cripple response capability. A critical strategic consideration should be how your agency staffing patterns and response times will change if you lose 30% of your work force. Discussions with the labor unit requires agreement on what will be a trigger to change staffing patterns and what sequence of brownouts will occur when there is no staff to fill shifts given little or no notice. An agency may consider not staffing a fire engine with four people in order to staff two ambulances as the need for ambulances grows. The private ambulance industry also will lose a similar percentage of its personnel. Meanwhile, increased volume from nursing homes and senior centers may place an unusually heavy demand on the ambulances, as seniors are particularly vulnerable to flu and pneumonia.

Expect service interruptions, everything from utilities, fuel and food to medical supplies and spare parts for emergency vehicles. How much fuel and food is in your community? With the new EPA regulations on underground fuel storage, many agencies are now more reliant on fuel from third party and local fleet fueling or service stations. You should identify at least one source of a secured fuel station.

Many businesses and governments operate with just-in-time inventory. This year, we have seen routine shortages in dextrose, epinephrine and other medications — and these are relatively normal times. Oxygen most likely will be in short supply. The just-in-time inventory and the consolidation of manufacturers make acquiring excess supplies with short notice difficult, especially when others are looking for the same materials. The shortage of N95 masks by many of the major suppliers at the start of the H1N1 pandemic should be an indicator of the kinds of supply disruptions that may arise. Try locating an alternator for an ambulance on a Friday if you are a small or midsize city that doesn't have a municipal garage with a large parts department. The maintenance shops and mechanical supply upon which your department relies also should be assessed.

Even more important is to evaluate areas of your supply chain that receive materials from the Far East. Flu generally emerges in China and Southeast Asia and travel restrictions may slow trade routes and the delivery of materials needed for continuity of operations. A triple redundancy of suppliers should be in place for critical items.

Many agencies received stockpiles of medications, including antivirals and antibiotics, prior to the start of H1N1. However, by the time a trigger could be identified that would launch distribution of the medication, the event was over. While the Centers for Disease Control and Prevention have on its Web site prescribing information for all interventions, this should be combined with infection-control practices, such as good hand hygiene and cough etiquette. Tamiflu has its limitations; for example, it sometimes has unusual effects on children and certain strains of the flu are resistant to the drug.

In addition, there still is some debate on the use of Pneumomvax for healthcare workers. It's difficult to understand why. The vaccine for pneumonia could provide some protection for health-care workers. Many of those who die after contacting flu do so because they contracted a secondary infection — usually pneumonia — while they were in a weakened state. Doesn't it seem logical then that healthcare workers, especially ones with asthma or respiratory disease, should be vaccinated for pneumonia?

In a pandemic, it would not be uncommon to see schools closed for up to 12 weeks. For families with two parents who work, the need to have one parent stay home to handle children in such a circumstance could place a strain on departmental operations. As a result, several jurisdictions had planned on closing city or county facilities during the H1N1 event, such as recreation and small convention centers, and using staff to handle child care for employees' children who normally would be in school.

As of Sept. 1, 2010, H1N1 influenza disease activity had returned to levels normally seen for seasonal influenza. It is expected that this virus will behave as a seasonal influenza A virus during this flu season. At this stage, however, it is important to maintain surveillance through www.cdc.gov/flu and www.google.org/flutrends, for current flu activity; any updates to the flu situation this year will be posted quickly on one of these two sites. Google caught flu outbreaks before the CDC because its search engine looks for purchases of flu-related over-the-counter medications and tracks people searching for flu-related topics.

Update pandemic preparedness and response plans accordingly. Remember that flu typically has two runs in a population. Forgetting the past dooms one to repeat it. It is our responsibility as the community safety net to ensure our continuity of services. Take a break from budget woes and ensure that you've asked the "what if" questions of your agency as they relate to pandemic flu.

Bruce Evans is the EMS chief for the North Las Vegas (Nev.) Fire Department. He also is the fire science program coordinator at the Community College of Southern Nevada and an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. He has an associate's degree in fire management and a master's degree in public administration.

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CDC’s Pandemic Severity Index

Characteristics	Category 1	Category 2	Category 3	Category 4	Category 5
Fatality Ratio (%)	<0.1	00.1 — 0.5	0.5-1	1-2	>2
Excess Death Rate (per 100,000)	<30	30-150	150-300	300-600	>600
Illness Rate (% of Population)	20-40	20-40	20-40	20-40	20-40
Potentional Number of Deaths (based on 2006 U.S. Population)	<90,000	90,000-450,000	450,000-900,000	900,000-1.8 million	>1.8 million
20th Century U.S. Experience	Seasonal Influenza (Illness rate 5-20%)	1957, 1968 pandemics	None	None	1918 pandemic