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Unformatted text preview: Pandemic Exercise Pandemic Public Health Responses Public Centers for Disease Control and Prevention (CDC) World Health Organization (WHO) Local public health offices Private health providers & hospitals Public education – individual and family preparedness Public Health Issues Public Surveillance and warning Prevention immunization Quarantine Hospital and other medical surge capacities History of Pandemics History Evidence of large scale pandemics – decreasing gene pool – “lost” civilizations Black Death Black Death Black 13471351 – killed up to onethird of the population of Europe – one half to two thirds of the population of Iceland 1330s – outbreak in China 1347 on – outbreak in Cairo, Egypt, and spread to cities in Middle East, including Mecca Influenza (or Flu) Influenza The flu is a contagious respiratory illness caused by a virus. It can cause mild to severe illness, and at times can lead to death. A person infected with the flu virus can transmit it onetwo days before they have symptoms. A person infected with the flu virus can transmit it fourfive days after symptoms start. Influenza Spread Influenza
Spread by contact with an infected person through: Sneezing Coughing Touching items recently contaminated by a person with the flu virus Influenza is a serious illness Influenza * Average annual estimates during the 1990’s Annual deaths: 36,000* Hospitalizations: >200,000* Who is at greatest risk for serious complications?
• • • • • persons 65 and older persons with chronic diseases infants pregnant women nursing home residents Influenza Types Influenza Type A
• • • Epidemics and pandemics Animals and humans All ages Type B • Milder epidemics • Humans only • Primarily affects children Pandemic influenza: definition Pandemic Global outbreak with:
• • • Novel virus, all or most susceptible Transmissible from person to person Wide geographic spread Impact of Past Influenza Pandemics/Antigenic Shifts Pandemics/Antigenic
Pandemic, or Antigenic Shift 191819 (A/H1N1) 195758 (A/H2N2) 196869 (A/H3N2) 197778 (A/H1N1) Excess Mortality 500,000 70,000 36,000 8,300 Populations Affected Persons <65 years Infants, elderly Infants, elderly Young (persons <20) Pandemic Waves Pandemic Pandemics occur in multiple waves of disease outbreaks The first wave in a local area is likely to last six to eight weeks The time between pandemic waves varies and cannot be easily predicted. Pandemic Severity Index Pandemic
Category Potential Number of Deaths 1 2 3 4 5 Less than 90,000 90,000 to 450,000 450,000 to 900,000 900,000 to 1.8 million 1.8 million or more Occurrences Schools Seasonal Influenza Close Contact Limit Adult Not Recommended Not Recommended 1957,1968 Consider up to Pandemics a Month None None 1918 Pandemic Consider up to a Month Consider up to a Month Recommended up to 3 Months Recommended up to 3 Months Consider up to a Month Recommended up to 3 Months Recommended up to 3 Months Source: CDC, February 2007. As of August 23, 2009 As Deaths = 556 Hospitalizations = 8843 Reporting States and Territories = 52 Not the same as seasonal influenza seasonal The age groups affected by the pandemic are generally younger. This is true for those most frequently infected, and especially so for those experiencing severe or fatal illness. To date, most severe cases and deaths have occurred in adults under the age of 50 years, with deaths in the elderly comparatively rare. This age distribution is in stark contrast with seasonal influenza, where around 90% of severe and fatal cases occur in people 65 years of age or older. ( Severe respiratory failure Severe Clinicians from around the world are reporting a very severe form of disease, also in young and otherwise healthy people, which is rarely seen during seasonal influenza infections. In these patients, the virus directly infects the lung, causing severe respiratory failure. Saving these lives depends on highly specialized and demanding care in intensive care units, usually with long and costly stays. The need for intensive care as the greatest burden on health services. Preparedness measures need to anticipate this increased demand on intensive care units, which could be overwhelmed by a sudden surge in the number of severe cases. Vulnerable groups Vulnerable An increased risk during pregnancy is now consistently welldocumented across countries. Data continue to show that certain medical conditions increase the risk of severe and fatal illness. These include respiratory disease, notably asthma, cardiovascular disease, diabetes and immunosuppression. Many of these predisposing conditions have become much more widespread in recent decades, thus increasing the pool of vulnerable people. Obesity, which is frequently present in severe and fatal cases, is now a global epidemic. WHO estimates that, worldwide, more than 230 million people suffer from asthma, and more than 220 million people have diabetes. Higher risk of hospitalization and death hospitalization Several early studies show a higher risk of hospitalization and death among certain subgroups, including minority groups and indigenous populations. In some studies, the risk in these groups is four to five times higher than in the general population. Although the reasons are not fully understood, possible explanations include lower standards of living and poor overall health status, including a high prevalence of conditions such as asthma, diabetes and hypertension. Implications for the developing world developing Such findings are likely to have growing relevance as the pandemic gains ground in the developing world, where many millions of people live under deprived conditions and have multiple health problems, with little access to basic health care. As much current data about the pandemic come from wealthy and middleincome countries, the situation in developing countries will need to be very closely watched. The same virus that causes manageable disruption in affluent countries could have a devastating impact in many parts of the developing world. Co-infection with HIV Co-infection The 2009 influenza pandemic is the first to occur since the emergence of HIV/AIDS. Early data from two countries suggest that people coinfected with H1N1 and HIV are not at increased risk of severe or fatal illness, provided these patients are receiving antiretroviral therapy. In most of these patients, illness caused by H1N1 has been mild, with full recovery. On current estimates, around 33 million people are living with HIV/AIDS worldwide. Of these, WHO estimates that around 4 million were receiving antiretroviral therapy at the end of 2008. 1918 Spanish Flu Pandemic Pandemic
The Reference Point for Future Pandemics Pandemic Vaccine Pandemic Annual vaccine is trivalent (3 strains), pandemic vaccine will be monovalent. Production using current technologies would likely take 45 months may not be available before 1st pandemic wave There will be vaccine shortages initially 2 doses may be necessary to ensure immunity Influenza control: antiviral medications medications Uses Issues • Prophylaxis • Treatment • Limited supply • Need for prioritization (among risk groups and prophylaxis versus treatment) • Unlikely to markedly affect course of pandemic Influenza control: infection control control influenza isolation precautions*
• • Private room or with other influenza patient Negative air pressure room, or placed with other suspected influenza cases in area of hospital with independent air supply • Masks for HCW entering room • Standard droplet precautions (hand washing, gloves, gown and eye protection) * 1994 Guidelines for Prevention of Nosocomial Pneumonia Infection control, cont’d Infection Feasibility of these measures in a pandemic setting is questionable, priorities should include:
• Droplet transmission precautions (use of masks and hand hygiene) • Cohorting of influenzainfected patients Influenza control: other control measures measures Education to encourage prompt self diagnosis Public health information (risks, risk avoidance, advice on universal hygiene behavior) Hand hygiene Face masks for symptomatic persons School closures (?) Deferring travel to involved areas Influenza control: quarantine Influenza Challenges
• • Not used during annual epidemics Could potentially slow onset of a pandemic before sustained persontoperson transmission has been established short incubation period for influenza a large proportion of infections are asymptomatic • clinical illness from influenza infection is non specific Medical care during an influenza pandemic influenza Surge capacity of the hospital system is limited. Challenges:
• • • Magnitude and duration Staff shortages Limited ability to call in external resources Pandemic Influenza Preparedness and Response Plan Pandemic Prioritization for Immunization
1. 2. 3. 4. 5. 6. 7. 8. Health care workers directly caring for patients (9 million) and drug plant employees (400,000); Highrisk patients over 65 with chronic conditions that increase risk of influenza; ages 6 months to 64 years with two such chronic conditions; people hospitalized in past year with influenza, pneumonia or a chronic condition (25 million); Pregnant women and people in a household with infants or severely immunecompromised people (11 million); Key government leaders and critical public health personnel (150,000); Other patients at risk; all seniors; anyone with a chronic condition; and children 6 to 23 months of age (59 million); Other public health workers and public safety personnel, including utility and some transportation workers (8.5 million); Key government health decisionmakers and funeral home workers (500,000); and Other Americans Triage in a Pandemic Low Priority Patients People over 85 years old Those with severe traumas, e.g., from car crashes, shootings, etc. Severely burned patients over 60 Those with mental impairments, e.g., advanced Alzheimer’s disease Those with severe chronic disease, e.g., advanced heart failure, lung disease or poorly controlled diabetes Healthy Hygiene Healthy Clean hands often
• • Cover mouth and nose when you sneeze or cough and clean hands afterwards Keep hands away from face Stay away from people who are sick Wash with soap and water or Clean with hand sanitizer Prepare at Home Prepare Plan now to care for yourself or loved ones who get the flu. Determine what supplies you will need to provide care at home. Plan how you will care for someone in your household who becomes sick. Exercise Exercise
The Next Flu Pandemic (Not this one) Early October 2009 Early There have been no major public health emergencies in Atlanta metropolitan area during the last several months. The regular flu season in the fall of 2009 begins, and the number of flu cases is mild to average (comparable to most other years). Mid-October 2009 Mid-October Atypical outbreaks of severe respiratory illness are discovered in various areas in Indonesia. At first, the Indonesian government attempts to contain the outbreaks on its own. The global community becomes aware of the outbreaks through rumors that the Indonesian government initially denied but later confirmed. Initial laboratory results from Indonesia’s National Influenza Center indicate that the outbreaks are due to influenza A, subtype H5. Late October 2009 Late Isolates from Indonesia are sent to the WHO Reference Laboratory at the US Centers for Disease Control and Prevention (CDC) for subtyping. WHO and CDC both identify the outbreak virus as a subtype H5N1. Outbreaks of the illness begin to appear throughout Southeast Asia in Hong Kong, Malaysia, and Thailand. Late October - continued Late Young adults appear to be the most severely affected. The average attack rate in these countries is 25%, and the average case fatality rate is 5%. Results of the WHO investigations indicate extensive persontoperson transmission of the virus, over at least 4 generations of transmission. WHO officially declares transition to pandemic alert level 5. Decisions to be made Decisions
1. 2. What are the specific actions that you (as an individual) should take in anticipation of pandemic? Assuming that your organization cannot simply shut down, what actions should your organization take in anticipation of pandemic? Early December 2009 Early The CDC reports localized outbreaks of the illness (due to influenza H5N1) confirmed in California and Arizona Recent reports from the CDC’s Influenza Surveillance System suggest that there is no reason to suspect the illness has yet reached Georgia Decisions to be made
1. 1. 2. What advice should organization executives give to employees about the threat of pandemic in the U.S.? What about travel to affected states or the West Coast in general? What specific key tasks should your organization or community engage in to prepare for the outbreak before it reaches Georgia? Mid December 2009 Mid The national media continue to cover pandemic flu stories. The local press contacts Fulton County Public Health to inquire about what the health agency and its healthcare partners are doing to prepare. Decisions to be made
1. 1. 2. 3. On whom should the organization rely for information? The county board of public health? State officials? DHHS? What are the key things that need to be done to ensure proper management of risk communications among employees? What are the key messages employees should be told at this point in time? Late December 2009 Late The infection control coordinator (ICP) from Grady Hospital reports an unusually large number of cases with fever and cough reporting to the Emergency Department in the last 24 hours. Onefourth of the organization’s employees call in sick or simply do not report for work. Fifteen percent of the employees call in to say that they have to stay home to take care of children or other family members. Decisions to be made
1. 1. 2. What key steps should be taken to assure that critical functions and processes continue? What should the organization be doing at this point to control the spread of disease among employees, customers, and others? Early January 2010 Early A global influenza pandemic is confirmed by WHO. The outbreak spreads throughout Georgia with some counties citing early estimates of around 25% of the population falling ill and a 5% case fatality rate. Hospitals and outpatient clinics in Atlanta and the surrounding areas have reached capacity. The best estimates right now are that more than 50,000 individuals in Atlanta alone have fallen ill and that around 16,500 have died. The organization’s chief information officer and at least a dozen other employees have died and dozens more are hospitalized. Mid January 2010 Mid Local health facilities across Georgia are reporting staffing shortages, some functioning with only half their staffs. A significant number of doctors and nurses and other critical infrastructure staff are also unavailable, either because they are ill or have not come to work. Local pharmacies, health care providers, and hospitals across the state are reporting shortages of antivirals as well as diminishing supplies, especially of ventilators, gloves, masks and lab supplies. Decisions to be made
1. 1. 2. What strategies might your organization use to manage large staffing shortages? What essential functions must remain in place for civil society? Police, fire, garbage collection, water system, energy grid, food delivery, etc.? Mid-February 2010 Mid-February The CDC begins shipment of vaccine across the country. It has identified health care providers, elderly, and people with chronic diseases as priority populations. Two doses of the vaccine will be required and Atlanta receives an initial shipment of 100,000 doses to vaccinate high priority groups. More vaccine is expected in the coming weeks. ...
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