Preparing for a ‘Newdemic’
Speakers Take on Public Health Emergencies
By Julie McDowell
During public health disasters, such as Hurricane Katrina and the 2004 tsunami in Thailand, point-of-care testing (POCT) was one of the few operational and reliable diagnostic tools available for immediate on-site diagnosis, and therefore should be the foundation of both emergency preparedness and rescue strategies, according to Gerald Kost, MD, PhD, MS, FACB, who has spent the last 3 years leading research teams who are analyzing medical responses to these events.
As a result of his research, Kost coined the term “newdemics,” which he defines as unexpected and disruptive problems that are affecting the health of large numbers of individuals in a crowded world, such as Hurricane Katrina, tsunamis, earthquakes, and pandemic influenza. “The current situation in preparing for a newdemic is problematic,” said Kost, who is the Director of the Point-of-Care Testing Center for Teaching and Research (POCT•CTR), Pathology and Laboratory Medicine, at the University of California Davis School of Medicine. “Generally, in the United States, we are not prepared with POC testing, and Katrina demonstrated that POCT is needed. Furthermore, industry should develop robust POCT instruments and supplies.” Kost will be moderating the morning symposium, “Diagnostic and Healthcare Strategies for Critical Care and Disaster Readiness,” on Wednesday at 10:30 a.m., and delivering a talk during the session, “Preparing Point-of-Care and Critical Care Testing: The Tsunami, Hurricane Katrina, and Earthquakes.” He will be joined by Dr. Lia Partakusuma from the Clinical Pathology Society of Indonesia (Jakarta), who will be discussing “Challenges of Diagnosing Acute Infectious Diseases in Indonesia.”
Kost’s research in Thailand during 2003–2004, which was funded in part by a Fulbright Scholar Award, has provided valuable perspectives about the basic laboratory services necessary to support medical care during acute disaster situations, explained Kent Lewandrowski, MD, Associate Chief of Pathology and Director of Clinical Services (Anatomic and Clinical) at Massachusetts General Hospital in Boston, as well as Editor-in-Chief of Point of Care. “Kost addresses emergency preparedness, which is something that has clearly proven to be a problem with major disasters, whether they have been in countries outside the United States or within this country,” he explained. “When there is a disaster that affects an entire region, it can disable the medical care delivery system, and an important part of this system is the ability to provide basic laboratory support for patient diagnosis and treatment.”
Kost has also found a supporter in Nobel prize recipient and former U.S. President Jimmy Carter, with whom he has discussed the role of POCT and the challenges of global public health. “The greatest single challenge faced by the world in this century is the growing chasm between the rich and the poor,” Carter wrote Kost in December 2004. “Delivering a diagnostic opportunity to the poverty-stricken people of the world and furnishing already known and tested treatment would be the greatest life-saving contribution.”
Learning from Katrina and the 2004 Tsunami
In order to optimize the role of POCT in disaster and emergency situations, Kost traveled to Thailand in early 2005 and again this year to assess how these diagnostic testing tools were used during the tsunami that occurred on Dec. 26, 2004. While the tsunami lasted only about 2 hours, it killed more than 310,000 people and cost the country almost $1 billion in capital, income, and medical losses. After interviewing numerous physicians, nurses, and laboratory technologists at primary care units (PCUs) and hospitals in the four Thai provinces hit hardest by the tsunami, Kost and his research team concluded that limited availability and poor organization hampered POCT use (Am J Clin Pathol 2006;126:513–520). In addition, transportation failures and a sudden load of critically ill patients also led to excessive deaths.
In comparison to these findings on POCT and the tsunami, Kost and his researchers found that following Katrina, rescue teams traveling via water, land, and air were able to bring equipment, such as glucose meters and whole-blood analyzers, as well as POC tests for infectious diseases to evacuees and flood victims. Even though POCT supplies were limited and in some cases unavailable, especially during the first days of the disaster, this technology demonstrated its value—and feasibility—during Katrina, he concluded.
In addition to these findings, Kost’s research also found that during these disasters, the victims included many who were self-monitoring for glucose or anti-coagulation. “In the event that they are cut off from their glucose strips or other POC testing devices, they may completely lose the ability to take care of themselves,” said Lewandrowski. “Kost has highlighted the importance of the self-testing patient population. In a disaster, some could be in serious condition if they are not able to maintain their blood glucose, so they need devices and insulin in order to be stable.”
These testing supplies must also be robust enough to withstand all conditions—including extreme ranges of humidity, temperature, salinity, altitude, and earthquake shock. “If this is done, then we wouldn’t have to rely on stockpiling POCT instruments and supplies, as specific reagents could be manufactured to have a longer shelf life,” explained Kost. At this week’s meeting, POCT•CTR Research Assistant Stephanie Sumner and her colleagues will present a poster that shows the vulnerability of POCT test strips and cartridges to environmental stress.
Coordination through Small-World Networks
The experiences with Katrina and the tsunami revealed the weaknesses in public health response both in the U.S. and abroad, and lead to renewed emphasis from state and federal officials that each hospital or healthcare facility must have an emergency and disaster preparedness plan in place. For clinical laboratories, plans must ensure operation despite power outages, flooding, a skeleton staff, and other disruptions likely to occur in these emergencies, explained Kost, adding that plans must also not rely on assistance from the federal government. In May 2006, the U.S. Homeland Security Council’s Pandemic Influenza Implementation Plan stated that the “center of gravity of the pandemic response” is at the state and community level, further underscoring the need to localize disaster planning.
Kost recommends that every facility develop its own disaster plan, with provisions for POCT and supplies. However, these POCT plans should be developed in conjunction with local and regional response plans. “Katrina and the tsunami revealed that coordination is necessary,” he explained. “Katrina showed that the U.S. is ill-equipped and ill-prepared on a federal planning level. It was even worse in Southeast Asia following the tsunami. We cannot wait for government agencies or public health officials to provide the leadership—hospitals must cooperate with each other by developing small-world networks.” Indeed, Kost has found that guidance from federal resources on incorporating POCT into disaster planning is virtually non-existent. Upon reviewing disaster planning and strategy documents from international and national resources including the World Health Organization and the Department of Homeland Security, he found little or no mention of POCT as a component of critical care response, according to his research published in the December 2006 issue of Point of Care (2006;5(4):138–144).
To supplement the lack of direction from these federal and international sources, Kost recommends that each hospital form a disaster medical assistance team (DMAT) that can travel and function for at least 3 days. “Clinical chemists and clinical pathologists should be represented on each facility’s DMAT so they can train POC operators and assure quality,” said Kost.
In his Point of Care article, he defines a small-world network as a “loosely tied but well-connected set of nodes” and explains that these networks allow information to move quickly between nodes in order to serve clusters of people faster. Small-world networks can help oversee and coordinate the DMATs and are headed up by decision makers who can allocate resources appropriately and triage patients to sites that are best suited to handle challenging medical problems. In addition, these networks would share authority, responsibility, financing, accountability, and accreditation for POCT deployment among nodal hospitals and acute care centers in order to improve overall efficiency, cost effectiveness, and evidence-based decision making.
Incorporating POCT into emergency and disaster preparedness is especially important because recent experience has shown that these events can—and will—happen at any time, noted Lewandrowski, who hopes that AACC meeting attendees will understand the role of the clinical laboratory and diagnostic companies in providing support for mobile rapid medical disaster relief situations. Kost also hopes that the clinical laboratory community realizes the challenges it has, as well as the diagnostic tools available to confront these healthcare trials.
“Humankind will face continued regional, national, and global challenges such as natural disasters and unpredictable acts that overwhelm even the richest nations,” wrote Kost in an editorial accompanying his 2006 Point of Care article. “The unique result is that, in the context of small-world networks, POCT has a clear and significant role, whatever the future may bring.”