THE THIN WHITE LINE: the history of a future avian influenza pandemic

Chapter 3: Pandemic

… Achoo, achoo,
We all fall down.

——children’s rhyme about Black Plague circa 1347

Not a mild virus

    After the first week of November ended, Canada began its third full week of the epidemic. When drawing up their pandemic response plans, public health officials had placed emphasis on predictions of a mild or moderate pandemic, in which they had projected a maximum of 8,000 hospital admissions at this time, about 1 percent of all infected.
    But H5N1 was not a mild virus. About one out of 10 people who became clinically ill from it needed hospitalization for complications such as pneumonia.(37)
     By the end of the second week more than 125,000 victims flooded the hospitals. In many health regions, the health system crashed. Demand simply exceeded all available hospital beds, not to mention ICU beds and ventilators.
    Everywhere, hospitals and clinics were shutting down.
    By the end of the third week, the number of cases requiring hospitalization almost doubled. Another 120,000 cases.
    Officials predicted that based on what they’d seen so far, they could end up with as many as another 550,000 cases by the end of the epidemic.

Figure 3-1. Clinically ill and hospital admissions in Canada over the course of the epidemic. The peak is clipped due to government interventions that reduced the rate of infection but extended the length of the epidemic.

    Hospitals like Mountain View soon found themselves in a virtual no-win situation. When a more common disaster such as a major fire results in mass injuries, a hospital can be stretched, but never broken by such an event. They can always count on help from the outside at some point. An epidemic of a major new disease is different. It’s an open event; everybody is going through it. The number of people needing treatment exceeds hospital capacity many times over, but no help will come from the outside, because they’re going through the same thing. No other hospital can help, no other province can help, no other country. Due to economic considerations, many hospitals also maintained a slim surge capacity——it could handle a sudden surge of so many patients, and no more. There simply weren’t enough resources to treat all of the infected.
    During the 1918-19 Spanish Flu Pandemic, the hospitals became so full they treated patients in corridors, offices and tents. Many patients, denied entry, were sent to gyms, state armories, churches and other facilities converted into emergency hospitals. Before the Pandemic of 2012-13, alternative care sites became recognized as an important feature of disaster planning, not just pandemic planning. For example, almost immediately following the World Trade Center attacks in 2001, an emergency triage was established at Chelsea Piers in New York City with the help of local hospitals.(38) After the devastation caused by Hurricane Katrina in 2005, several alternative sites became established. In one case, doctors and students from the University of Texas Southwestern Medical Center at Dallas set up a surge hospital at the Dallas Convention Center, staffed by volunteers, which received thousands of evacuees and treated nearly 9,000 patients September 1-16.(39)
    As the epidemic spread and engulfed Canada, the health system counterattacked by launching scores of alternative care sites.
    Health officials deployed a range of different types of alternative care sites during the Pandemic in Canada. Mobile field hospitals, contributed by the military and the national emergency stockpile, offered full services to increase hospital capacity. Flu treatment sites, essentially warehouses of beds for flu patients in facilities such as school gyms and hotels, focused on isolating and caring for victims of the flu. Some provinces created flu recovery sites, which provided beds for patients who have begun recovering and had minimal medical needs. And some created expanded ambulatory care sites, which cared for non-flu patients, and triage and patient screening sites, where people with influenza-like symptoms could be quickly diagnosed and told where to go for treatment. Overall, the establishment of emergency hospitals increased healthcare capacity by about 25 percent, but still it wasn’t enough for all of the flu victims who would seek treatment.
    Staffing proved the biggest problem in producing and maintaining these sites during an exponentially spreading epidemic and atmosphere of crisis. Plenty of people volunteered, but health skills remained a scarce commodity throughout the epidemic, gradually becoming even scarcer over time.