Case Study: Pandemic Flu Scenario

January 11, 2007 Newark, NJ

This public health case study was developed by the Center for Public Health Preparedness at the State University of New York at Albany. It has been adapted by the New Jersey Preparedness Training Consortium and Rutgers Nursing Center for Bioterrorism and Emerging Infectious Disease Preparedness for use in training health care professionals under HRSA Grant No. T01HP01407

RUTGERS COLLEGE OF NURSING CENTER FOR PROFESSIONAL DEVELOPMENT

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New Jersey Preparedness Training Consortium www.nj-ptc.org

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Ground Rules

• Play yourself, but think outside your usual role • No wrong answers; try to find better ones • Avoid jargon and define acronyms • Assume the information is accurate even though the scenario is hypothetical • Facilitators are here to help you to think through possible answers from multiple perspectives • No one person is expert in all areas but we are here to learn how different groups might interact in an emergency setting 3

Rutgers Nursing Center for Bioterrorism & Emerging Infectious Diseases Preparedness Facilitators

• Mary L. Johansen MA, RN, Project Manager, The Nursing Center for Bioterrorism and Emerging Infectious Disease Preparedness • Miriam Cohen, MS, RN, APN, Director of Disaster Preparedness, New Jersey Primary Care Association • Joy Spellman, MSN, RN, Director, Center for Public Health Preparedness 4

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Objectives

Discuss the impact of an influenza pandemic on your community, organization, partner organizations, and professional activities Identify problems and potential solutions that are unique to your agency and community Cite the identified problems and solutions with your peers State the proceeding and recommendations made by the group in order to recognize the unique perspective of public health in planning efforts.

State how critical thinking may be applied when using simulation.

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It’s There!

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Background

June 2005

• For months the health care and public health community worldwide has been watching and studying the avian influenza A/H5N1 virus that has continued to evolve in southeast Asia.

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Background

• The recent outbreaks that began in December 2004 have resulted in 59 cases and 22 deaths in southeast Asia.

• To date no cases of human-to-human transmission have been confirmed.

Source: WHO. June 16, 2005.

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What Makes a Pandemic?

• Novel virus sub-type must emerge to which the general population has no or little immunity • New virus must be able to replicate in humans and cause serious illness • New virus must be transmissible from human to human giving it the capability of causing community-wide outbreaks Weir E. CMAJ 2005;173:869-70.

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Avian Influenza:

The Virus

library.wur.nl/frontis/avian_influenza/

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Mortality Due to Influenza

The red line indicates observed deaths. The middle line or epidemic threshold is the upper limit of expected deaths over an average of 5 years. The bottom line is the baseline death rate. Excess morbidity & mortality is the difference between the two top lines. Note ↑ in 2002 and 2004. Deaths from flu & pneumonia usually range between 8.5-10.4%

http://www.medscape.com/viewarticle/517503_3 11

Prophylaxis and Treatment of Influenza

MMWR Morb Mort Wkly Ret. 2003:52(RR-8):1-36 12

How Oseltamivir Works

Moscona A . NEJM 2005; 353:1363-73 13

Lab Confirmed Cases of Human Avian Flu as of February 21, 2006

Case-Fatality Ratio (92/170 ~54%) 14 Adapted from http://europa.eu.int/comm/health/ph_threats/com/Influenza/ai_current_en.htm

. Accessed 5 March 2006

Suspicious Case

• In Hanoi, Vietnam a worrying case has come to the attention of the Ministry of Health.

• A migrant worker (identified only as Mr. W.) lies critically ill in an area health center with an influenza-like illness.

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Investigation

• Two days ago Mr. W. fell ill on the job at the Hotel Universal.

• According to the investigation, Mr. W. and several others left their home village to return to work in Hanoi, leaving sooner than planned because 4 residents of his village had died.

• The symptoms of the deceased were similar to what a companion suffered from after returning from a 2-day trip to a regional market town.

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Alert

• The WHO Global Influenza Surveillance Network reports the following on the situation in Vietnam: – Mr. W. has died, along with 8 other individuals from his village who recently returned to work in Hanoi hotels and private residences.

– Lab tests on collected samples from the victims have isolated a new strain of avian influenza A/H5N1.

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Alert

– Investigation concludes that human-to-human transmission

did

occur in these cases.

– The new strain is highly pathogenic.

– The new strain can cause primary viral pneumonia, unlike pneumonia in most influenza patients caused by secondary bacterial infection.

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Outbreak

• Initial investigation in the last 24 hours has revealed 26 other suspected cases in area homes and hospitals.

• Laboratory confirmation of the strain is expected soon.

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Situation Update

• The number of cases in Vietnam has grown to 62 confirmed by laboratory, 125 other under investigation, and 35 deaths.

• Neighboring countries of Laos, Thailand, and Cambodia have reported confirmed and suspect cases of influenza infection by the new strain.

• Some cases were quickly traced back to foreign travel and stays at the Hotel Universal in Hanoi.

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Situation Update

• The ministries of health in China, Indonesia and Canada report confirmed cases of infection by the new strain.

– Some cases are in health care workers who probably delivered care to infected travelers.

– Previously unsuspicious cases in patients are being investigated retroactively.

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Casualty Report

Vietnam Laos Thailand Cambodia Canada

July 2005

Cases 62 12 17 4 6 Deaths 35 4 12 4 1 22

Coming and Going (1)

International air travel: • 2 million passengers per month arrive on international carriers at NYC airports • 1,400 passengers per month arrive directly from Canada at Albany International Airport.

The New York State Thruway serves 230 million vehicles per year.

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Coming and Going (2)

Daily traffic at the New York Canadian border: – Train passengers: 200 – Pedestrians: 1,800 – Bus passengers: 4,655 – Car passengers: 58,074

Source: Bureau of Transportation Statistics

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Discussion

• What questions from the public are likely?

• What should you do to prepare for outbreaks in your local area?

• To prepare, what new relationships would you need to form immediately?

• What resources can you call on to ease the psychological strain on the emergency response personnel?

• Flu response overwhelms routine health department activities; should routine disease surveillance and control cease?

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It’s Here!

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Local Outbreak

August 2005

• During the last week, 42 suspect cases of infection with the novel pandemic strain have been detected in New York State. • Four suspect cases reside in Bergen County, NJ.

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Source

• Investigation reveals that most transmissions occurred at a Fresh Air Fund summer camp session in Catskills.

• The session was attended by 240 campers from around the region.

• Counselors and staff included local residents as well as college students from foreign summer abroad programs.

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Surge

• Local hospitals are seeing a surge of patients in emergency departments.

• Political and health authorities are bombarded with questions about what to do.

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Vaccine Status

• There is no vaccine available.

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Casualty Report

August 2005

Global U.S.

New York Total Cases to Date Total Deaths to Date 2,730 1,150 750 231 420 106 Canada 670 150 31

Discussion

• Who should be involved in developing messages for the public?

• How might you use volunteer organizations to help respond?

• What are the pros and cons of implementing Unified Command for the NY-NJ regional response?

• What resources will you run out of quickest?

• How will you meet the needs of people isolated or quarantined at home? 32

Breathing Room

Cases

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Impact

December 2005

• The pandemic has not been stopped and the impact to date has been enormous… 34

Global U.S.

New York New Jersey Canada

Casualty Report

December 2005

Total Cases to Date Total Deaths to Date 322 million 7.7 million 14.8 million 177,600 950,000 11,400 350,000 1.6 million 4,500 19,680 35

End of First Wave

Cases

• In the northeastern US and most other parts of the country, the number of new outbreaks has reduced to a fraction of the rate during the peak 3 months ago.

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Vaccine Arrives

• Reaction is mixed – Fear of side effects – Demand greater than supply • Shortages occur at all levels: International, national, state, local, organization 37

Overseas

• Outbreaks continue abroad.

• Poor countries on every continent are experiencing local, savaging outbreaks in remote regions and mega-cities alike.

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Prioritization

• Many advocate prioritizing the military for vaccine, medications, equipment, and medical personnel to maintain national security.

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Psychosocial Impact

• After months of steady outbreaks, few lives are untouched by illness, death, bereavement, and stress.

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Vigilance

• Public health authorities stress the need to maintain infection control practices and surveillance.

• Many believe they can relax a bit now that the pandemic has lessened locally.

• History shows that another wave is likely.

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Political Tensions

• Some countries blame each other for not preventing or stopping the pandemic.

• Poor countries make pleas for financial aid and resources.

• Congressional scrutiny is constant.

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Discussion

• How do you address public concerns over flu vaccine?

• What problems and solutions are likely to arise with rapid vaccination efforts, given current POD planning and experience?

• What private agencies do you need/want to help with mass vaccination?

• Only half the expected vaccine arrives at your area: how do you prioritize who receives it?

• What are security concerns at PODs?

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It’s Back!

Cases

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Second Wave

July 2006

• Illness and death rates have crept back up again.

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On the Move

• Areas that normally serve only as vacation homes for urban dwellers now see unusually high population levels due to urban “Flu Flight”.

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Overtime

• The staff shortage in healthcare facilities is estimated to be an average of 40%, due to both inability and unwillingness to work.

• Available staff see shifts extended and vacation requests denied.

• Overtime pay and costs reach unprecedented levels.

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Now Hiring

• Demand for able and willing healthcare workers exceeds supply locally and internationally.

• Employers that are able to are offering enormous pay for temporary healthcare workers, as during the SARS outbreak of 2003 when Canadian hospitals paid up to $2,000 per day to physicians. 48

Respiratory Intervention

• Assumptions: • Anticipate > 20,000 deaths in NJ • 80% of decedents were intubated prior to death • 1/3 of intubated patients will die • Deaths are calculated as distributed evenly over 10 mos.

• All 115 NJ hospitals have equal capacity • Required ventilator capacity for flu only • 4,800 per month • 42 per month per hospital 49

Surge Capacity

• Auxiliary hospitals increase in size and number in temporary facilities and structures.

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Surge Capacity Question

• What is the surge capacity for your organization?

• Does it meet the required needs?

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Vaccination Campaign

• Immunization levels average 35%, with a range between 10% and 60%.

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Casualty Report

Global U.S.

New York New Jersey Canada

July 2006

Total Cases to Date Total Deaths to Date 644 million 15.5 million 29.6 million 1.9 million 355,200 22,800 750,000 1.9 million 9,500 39,360 53

Discussion

• What are the priorities for communication and education?

• What determines maximum capacity to provide care and services?

• Should specific hospitals be designated for treating flu patients?

• What resources cost the most but do the least general good? How do you allocate them?

• What are options to address mortuary capacity?

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Conclusion

• The rate of new infections with the pandemic strain have fallen to levels similar to non-pandemic strains, as have survival rates.

• Vaccine production and delivery continue to climb.

• Thorough evaluation of the response to this pandemic is on-going.

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Global U.S.

NY NJ Canada

Casualty Report

December 2006

Total Cases 967 million 44 million 2.9 million 1.5 million 4.9 million Total Deaths 23.2 million 532,800 34,200 18,500 59,040 56

Conclusion: Take-home

• Are we prepared to respond to pandemic flu?

• Individual • Local • Regional • National • International • What steps are your agency taking to prepare? 57

Disclaimer

• The scenario is hypothetical. The estimates of cases and deaths are NOT official projections of morbidity and mortality in the event of a flu pandemic. They are provided for illustration purposes only.

• Visit www.cdc.gov/flu/flusurge.htm

to make projections of the impact of flu in your locale based on variable assumptions. 58

Case Presentation

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• 40 y/o W male presents for evaluation complaining of non-bloody diarrhea of 48 hours duration • Recent return from rural northeast (Kurdish Autonomous Region) of Iraq after a 30 day business trip now concerned because of travel history 59

Case Presentation

• Physical – 40 y/o well developed

♂

in mild discomfort because of diarrhea and cough • BP=110/70 P=90 R= 22 T=101.9

• HEENT- Mucus membranes dry, no conjunctival injection • Chest – Mild wheezes, intermittent tachycardia up to 105 BPM • Abd-  bowel sounds with diffuse mild tenderness – no masses or point tenderness 60

Case Presentation

• Musc/Skel – 4/5 - 5/5 strength normal ROM • Neuro – non-focal examination • Labs sent, IV fluid started, X rays taken • CBC –Moderate↓ wbc and platelets • CXR- diffuse patchy interstitial infiltrate • ABG-moderate hypoxia with resp alkalosis 61

Case Presentation

• Sputum is non specific for pathogens • Swab (+) for Influenza but nonspecific • Patient vomits, aspirates and requires intubation to control airway and breathing • All hospital respirators are currently in use 62

Case Presentation

2

• 65 y/o male, recently retired. History of congestive heart failure presents in the emergency room for evaluation complaining of weakness, fever, cough, chills, SOB and loose stool today.

• Recently returned from a trip last week to Atlantic City with a senior group on a bus 63

Case Presentation

• Physical – 65 y/o male in moderate discomfort because of shortness of breath and cough • BP=160/92 P=108 R= 30 T=101.9

• HEENT- Mucus membranes dry, no conjunctival injection. LLE with 3+ edema.

• Chest – Moderate wheezes, new onset of atrial fibrillation up to 128 BPM • Abd-  bowel sounds with diffuse mild tenderness – no masses or point tenderness 64

Case Presentation

• Musc/Skel – 3/5 - 3/5 strength normal ROM • Neuro – non-focal examination • Labs sent, IV fluid started, Lasix given IV, X rays taken • CBC –Moderate↓ wbc and platelets • CXR- diffuse patchy interstitial infiltrate • ABG-moderate hypoxia with resp alkalosis 65

Case Presentation

• Sputum is non specific for pathogens • Swab (+) for Influenza but nonspecific • Intake and Outake monitored.

• Responds to diuretics and Tamiflu, (

oseltamivir)

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Acknowledgements

• References & Sources: – WHO Global Influenza Preparedness Plan – WHO Checklist for Global Influenza Pandemic Preparedness Planning – FEMA, HHS: Pandemic Tabletop, 1999.

• Exercise guidelines adapted from FEMA • Case made available to NJPTC through NJ Center for PH Preparedness in partnership with SUNY Albany Center for PH Preparedness 67

Helpful Web Sites

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http://bioterrorism.rutgers.edu/ www.cdc.gov

www.who.in/en/ www.fao.org

www.oie.org

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