Transcript Forced Protection - Emergency management

Texas Division of Emergency
Management Conference 2012
“Force Protection”
During a Pandemic Influenza
Ricky Reeves, Division Chief, Lewisville Fire
Catastrophic Guidelines and Triage Subcommittee
Mike Megna, Retired, UTMB
Catastrophic Guidelines and Triage Subcommittee
Summer Wilhelm, CEM, City of Lewisville
Three Kinds of Influenza
• Seasonal Influenza “The Flu”
–
–
–
–
–
Can be transmitted person to person
It is predictable, typically seen in the winter months.
Most people have some immunity
Vaccine is available
Minor impact on the community and economy
• Avian Influenza “Bird Flu”
– Disease primarily of birds—not readily transmitted from birds to
humans
– No human immunity
– No human vaccine is commercially available
• Pandemic Influenza “A Pandemic”
–
–
–
–
Novel virus emerges
Little or no natural immunity
Can spread easily from person to person –causes illness
No vaccine available
The Flu Virus as a Contagion
DANGER OF INFECTION
Infectious (Shedding Virus)
Day 0
Recovering
Incubation
Symptomatic (Sick)
Work, etc.
Work/Home/Hospital Back to work, etc
Day 2
Day 4
Day 11
Day 15
How Do Influenza Pandemics
Arise?
• When avian influenza viruses experience sudden
changes in genetic structure
And
• Are capable of infecting humans
And
• Can reproduce and spread from person to person….
a pandemic occurs
• H5N1 has two of the three today.
Pandemic Assumptions
• A pandemic in the United States could result in 20-35% of
the population becoming ill, 3% being hospitalized, and a
fatality rate of 1%.
• A pandemic in the United States could result in up to 40%
absenteeism rate that will exacerbate personnel shortfalls
resulting from hospitalization.
• Others will need to tend to children or sick family
members.
• 40% of children will be sick.
• Some will stay home as a protective step.
• In a pandemic, anticipate a 25% increase in requirements
for all categories of medical support.
Why the Concern About
Pandemic Influenza?
• Influenza pandemics are inevitable;
naturally recur at more or less cyclical
intervals.
• Experts: predict the next “big one”
is H5N1, it is inevitable….
• Other experts: It may happen now,
or over the next several years….
• The pandemic flu clock is ticking, we
just don’t know what time it is.
Influenza: The Flu Cycle
Pandemic influenza: definition
• Global outbreak with:
– Novel virus, all or most susceptible
– Transmissible from person to person
– Wide geographic spread
The Pandemic Threat
• Influenza viruses have threatened the health of animal and
human populations for centuries.
• Their diversity and propensity for mutation have thwarted our
efforts to develop both a universal vaccine and highly effective
antiviral drugs.
• A pandemic occurs when a novel strain of influenza virus
emerges that has the ability to infect and be passed between
humans.
• Three human influenza pandemics occurred in the 20th
century, each resulting in illness in approximately 30 percent
of the world population and death in 0.2 percent to 2 percent of
those infected
• Using historical information and current models of disease
transmission, it is projected tha a modern pandemic could lead
to deaths of 200,000 to 2 million people in the United States
alone.
Pandemics of influenza
Recorded human pandemic influenza
(early sub-types inferred)
H2N2
H2N2
H1N1
H1N1
H3N8
1895 1905
1889
Russian
influenza
H2N2
1915
Pandemic
H1N1
H3N2
1925
1900
Old Hong Kong
influenza
H3N8
1955
1918
Spanish
influenza
H1N1
1965
1957
Asian
influenza
H2N2
1975
1985
2010
2015
H9* 1999
H5 1997 2003
H7 1980
Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus
Research,
National Institute of Infectious Diseases (NIID), Japan.
2005
2009
Pandemic
influenza
H1N1
1968
Hong Kong
influenza
H3N2
Recorded new avian influenzas
1955
1995
1965
1975
1985
1996
1995
2002
2005
Animated slide: Press space bar
Impact of Past Influenza
Pandemics/Antigenic Shifts in US
Pandemic, or
Antigenic Shift
Excess Mortality
Populations
Affected
1918-19
(A/H1N1)
1957-58
(A/H2N2)
1968-69
(A/H3N2)
1977-78
(A/H1N1)
650,000
Persons <65 years
70,000
Infants, elderly
36,000
Infants, elderly
8,300
2009
(A/H1N1)
12000
Young (persons
<20)
Healthy Young
(persons <25)
The 1918 Influenza
Pandemic
Major Pandemic: Historical Clues
1918: ‘Spanish’ Flu
-Major pandemic: 20-40 million
deaths worldwide
-Targeted young, healthy adults:
rapid death from respiratory failure
-Several waves: next older patients
-Clinical attack rate: 25-40%
-Case fatality rate: 2-4%
-Slowed to a trickle the delivery of
American troops on the Western front.
- 43,000 deaths in US armed forces.
-Slow down and eventual failure of the
last German offensive (spring and
summer 1918) attributed to influenza.
America’s deaths from influenza were
greater than the number of U.S.
servicemen killed in any war
Thousands
900
800
700
600
500
400
300
200
100
0
Civil
War
WWI
1918-19 WWII
Influenza
Korean Vietnam War on
War
War
Terror
Minor Pandemic: Historical Clues
1957: Asian Flu
February: New strain H2N2 identified
Little prior immunity
Reassortant mutation (avian/human)
Minor pandemic
May: Vaccine production begins
June: Hits U.S. border quietly
September: “Back to school” outbreak, highest mortality
February 1958: “Second wave” amongst elderly
-Clinical attack rate: 25%
-Case fatality rate: 0.2%
-Total mortality: 70,000 in US, 1 million worldwide
Worldwide Spread in 6 Months
Spread of H2N2 Influenza in 1957
“Asian Flu”
Feb-Mar 1957
Apr-May 1957
Jun-Jul-Aug 1957
69,800 deaths (U.S.)
Minor Pandemic: Historical Clues
1968: Hong Kong Flu
-H3N2 strain: thought reassortant
-Target: Age over 65
-Clinical attack rate: 20-25%
-Case fatality rate: 0.1%
-Mortality: 35,000 US, < 1 million in world
Mildest 20th century pandemic
- Immunity from Asian Flu
- Better medical care, antibiotics
- Decreased secondary infections
- Similar to large epidemic
Avian Influenza Today: Asia
Southeast Asia:
Prime pandemic media
-Agricultural practices
-Cultural practices
-Proximity:
Human, bird, swine
Chance for reassortment
-Virus amplification with
poultry outbreak!!!
Avian Influenza Outbreaks
• Asia, Middle East, Africa: H5N1 (1997-2011)
– ~534 reported “cases”, ~316 deaths
• Vast majority cases not reported (case fatality unknown)
– Human infection, pathogenicity
• Most: well-documented exposure to sick/dying poultry
• Minimal human to human spread
• Netherlands: H7N7 (2003)
– 4500 poultry workers exposed
– 450 clinical illness with H7N7 (attack rate 10%)
– 1 death in veterinarian (case fatality 0.2%)
• No human to human spread
Current Status
Interpandemic
Pandemic alert
Pandemic
Phase 1
Phase 2
Phase 3
Phase 4
Phase 5
Phase 6
No new
virus in
humans
No new
virus in
humans
New virus
in
humans
Small
clusters,
localized
Larger
clusters,
localized
Animal
viruses
low risk
to
humans
Animal
viruses
low risk
to
humans
Little/no
spread
among
humans
Limited
spread
among
humans
Limited
spread
among
humans
Increased
and
sustained
spread in
general
human
population
Current
H5N1 status
Chance of Pandemic Influenza:
Avian Influenza?
• Why hasn’t AI already become pandemic?
– Genetic variability in avian strains
– Receptor binding and affinity in humans
– No reassortment yet
– Luck???
Pandemic Flu Today
Despite . . .
– Expanded global and national surveillance
– Better healthcare, medicines, diagnostics
– Greater vaccine manufacturing capacity
New risks:
–
–
–
–
–
Increased global travel and commerce
Greater population density
More elderly and immunosuppressed
More daycare and nursing homes
Bioterrorism
Are we more or less at risk
today compared to 1918?
Why at LESS risk in 2012
• Antibiotics for bacterial pneumonia
complications of influenza
• Some antiviral medicines
• IV fluids, oxygen, ventilators
• Greater ability to do surveillance,
confirm diagnosis of flu
Why at LESS risk in 2012
• Rapid means of communications internet, TV, radio, email
• More effective personal protective
equipment
• Fewer people living in each
household and more rooms.
Why at MORE risk in 2012
• A lot more international travel
• Contact with far more people daily
• Very little surge capacity in health care
today
• Greater reliance on health
professionals
Why at MORE risk in 2012
• More elderly and immunecompromised people in population
• Infectious disease deaths uncommon
• Much less self-sufficient than in
1918’s (households and businesses)
• Today’s society not used to rationing,
sacrifice, compared to war-time 1918.
Why at MORE risk in 2012
• Far more manufactured goods and
raw materials come from distant
areas, especially Asia
• “Just-in-time” ordering of needed
supplies instead of warehousing
critical items on site
Overall, are we at more or
less risk?
• Up to individuals, organizations,
communities, states, and nations to
decide as they plan for a possible
pandemic
What might happen in a
severe pandemic?
If it happens soon…..
• There will be little or no vaccine until
6 - 9 months after the outbreak begins
• There will be very limited supplies of
antiviral medicines for treatment (for 1% of
population, perhaps less).
• All communities hit a about the same time
• We need a plan for the short-term that
assumes no effective shots or Rx
What might occur
• High levels of absenteeism
• Health system could be overwhelmed
• Essential services could be at risk (fuel,
power, water, food, etc.)
• “Just-in-time” supply lines could be
disrupted
• High mortality rates could occur
• Social disruption could occur
Who Infects Whom?
To Children
To Teenagers
To Adults
To Seniors
Total From
From Children
21.4
3
17.4
1.6
43.4
From Teenagers
2.4
10.4
8.5
0.7
21.9
From Adults
4.6
3.1
22.4
1.8
31.8
From Seniors
0.2
0.1
0.8
1.7
2.8
Total
28.6
16.6
49
5.7
100
Likely Sites of Transmission
Schools
Demographics (2010)
Children/Teenagers
26.97%
Households
Adults
59.99%
Work place
Seniors
13.04%
A Typical Family’s Day
Carpool
Work
Lunch
Work
Shopping
Home
Car
Home
Car
Daycare
Bus
School
time
Carpool
Bus
Others Use the Same Locations
Time Slice of a Typical Family’s Day
Who’s in contact doing what at 10 AM?
Work
Shopping
Daycare
School
A Scared Family’s Possible Day
Home
Home
Force Protection
All services performed, provided, or arranged to promote,
improve, conserve, or restore the mental or physical wellbeing of personnel.
These services include, but are not limited to, the
management of health services resources, such as
manpower, monies, and facilities; preventive and curative
health measures; evacuation of the wounded, injured, or
sick; selection of the medically fit and disposition of the
medically unfit; blood management; medical supply,
equipment, and maintenance thereof; combat stress
control; and medical, dental, veterinary, laboratory,
optometry, medical food, and medical intelligence
services.
Consideration for Our Workforce
• You may be asked or required to do things
to limit the spread of disease in our
community.
• Isolation or Quarantine
• Comply with Social Distancing Measures
Protection of EMS/Fire and 9-1-1
Workforce and Families
• EMS will be treating influenza-infected patients and will
be at risk of repeated exposures.
• To support continued work in a high-exposure setting and
to help lessen the risk of EMS workers transmitting
influenza to other patients and EMS family members,
their protection must be given high priority
• The vulnerability of the healthcare workforce was
apparent when both Hong Kong and Toronto dealt with
SARS.
• Work with public health officials and occupational health
personnel to establish internal surveillance protocols and
tracking systems to monitor the health of workers
Protection of EMS/Fire and 9-1-1
Workforce and Families
• Mechanisms that could be sustained throughout a
pandemic period to maintain physical and mental
capabilities of providers
• Consider opportunities for off-duty EMS personnel to
have alternative housing arrangements during a
pandemic, thereby protecting providers from transmitting
disease to family members or visa versa
• Consider methods to offer prophylaxis/treatment to EMS
providers also consider methods to offer medications to
family members of personnel
• Encourage proper use of infection control measures and
personal protective equipment to reduce risk of exposure
EMS/Fire Infection Control and
Decontamination
• Adopt day-to-day infection control and decontamination
procedures consistent with the most recent CDC and
OSHA guidance
• Mechanisms of rapidly modifying infection control and
decontamination procedures based on the most recent
research and scientific information, including Federal,
State and local pandemic influenza guidelines
• Consider a screening algorithm to identify potentially
infected patients and ensure proper use of PPE and
infection control practices
• Consideration should be given to having in place social
distancing measures
Vaccines and Anti-Virals for
EMS/Fire Personnel
• Provide pharmaceutical countermeasures to
protect the EMS workforce are essential to
maintaining an EMS systems’ ability to satisfy
demand for services
• Maintain familiarity with Federal guidance on
prioritization of vaccinations and administration
of anti-viral medications
• Specific plan for the acquisition, distribution and
administration of pharmaceutical and nonpharmaceutical countermeasures to EMS and
9-1-1 personnel
Isolation and Quarantine
Considerations for EMS/Fire
• Establish policies for employees who have been exposed
to pandemic influenza or are suspected to be ill
• Clear expectation that staff do not come into work when ill
with a febrile respiratory illness and support this
expectation with appropriate attendance policies
• Establish policies on when a previously ill person is no
longer infectious and can return to work after illness
• Opportunities for off-duty EMS personnel to have
alternative housing arrangements during a pandemic
• Identify mechanisms to ensure freedom of movement of
EMS assets (vehicles, personnel, etc.) when faced with
restricted travel laws, isolation/quarantine or security
measures
EMS/Fire Protocols &
Dispatch Protocols
• Coordinate with public health and 9-1-1
officials and the local medical
examiner/coroner to define protocols and
processes for fatality management during
pandemic influenza.
• Consider “treating and releasing” patients
without transporting them to a healthcare
facility
Support for EMS/Fire Personnel
and Their Families
• Collaborate with psychosocial or mental health
professionals to assist in formulating messages and
communications strategies that will minimize negative
impacts on emergency workers by managing
expectations and helping achieve desired behaviors and
outcomes
• Providing additional support services, including mental
health services
• Coordinate with community resources to support workers
and their families at the onset, during, and following a
pandemic. (e.g., Community Emergency Response
Teams (CERT), the American Red Cross, faith-based
organizations, and other family assistance groups)
Hospital Force Protection
“Four Ss of Surge Capacity”
• Staff: Human Resources
• Stuff: Materials Required for Response
• Structure: Physical Facilities for care
delivery
• Strategy: Pre-planning an approach
Hospital Force Protection
Sheltering Needs:
• Professional Staff: Nursing, Medical,
Allied Health
• Support, Administrative Staff
• Dependents
• Care-Givers
• Extended Family
Hospital Force Protection
Sheltering Needs:
• Clergy / Pastoral Care
• Volunteers if utilized
• Security Staff
• Pets
Hospital Force Protection
Support Considerations:
• Housing Capabilities
• Food/Water for Increased Numbers
• Medications
• Laundry Capabilities
• Day Care / Elder Care
• Sanitation
Hospital Force Protection
Support Considerations:
• Incidentals (Commissary)
• Parking
• Access Control/Rosters/In – Out
(Badges?)
•Visitation Policy ?
•Contract Employees
•Vendors
• Local Public Safety – EMS, Law, Fire
Hospital Force Protection
Support Considerations:
• Additional PPE supplies
• Communications – Internal/External
• Data Capture / Documentation
• Mental Health Recovery – Traumatic
Stress Management
Hospital Force Protection
Support Considerations:
• Transportation, if housing is remote
• Social, Spiritual, Entertainment needs
• And: What happens when staff or
dependents become ill ?
Hospital Force Protection
Staffing Considerations:
Staff willingness to report for duty
•MCI 83% (able); 86% (willing)
•Environmental Disaster 81% (able); 84% (willing)
•Chemical Event 71% (able); 68% (willing)
•Smallpox 69% (able); 61% (willing)
•Radiological event 64% (able); 57% (willing)
•SARS 64% (able); 48% (willing)
Source: OSHA Pandemic Influenza Preparedness and Response
Guidance for Healthcare Workers and Healthcare Employers,
OSHA 3328-05R 2009
Hospital Force Protection
Cost Considerations:
All areas mentioned previously, plus:
• Cost of increased surveillance;
• Increased wage rate for extended
hours per person;
• Premiums on vaccine, PPE, other
short supply items
Hospital Force Protection
Cost Considerations:
• Availability of all goods will be a function of
vendor ability to produce them, transporters to
move them and healthcare staff to receive and
distribute them to point of use
• Every industry will be affected by
absenteeism, hospitalizations and deaths
• Significant interruptions in normal business
operations for some period of time
Hospital Force Protection
Planning assumptions in the National Strategy for Pandemic Influenza
Implementation Plan include a 30 percent attack rate in the U.S.
population, 50 percent of those ill will seek medical attention, and an
absenteeism rate of up to 40 percent.
The impact of pandemic influenza would be much greater than the impact
of SARS. HHS/CDC modeled a pandemic influenza crisis in the metro
Atlanta area with a 25 percent gross attack rate. The model estimated that
there would be 412 hospital admissions a day, with a total of 2,013 cases
hospitalized in one week during the peak of the
Outbreak.
This is about 4.5 times the number of patients hospitalized during the
Toronto SARS outbreak.
Source: Department of Health and Human Services Pandemic Influenza Plan, Supplement 10, available at
http://www.hhs.gov/pandemicflu/plan/sup10.html#I.
Goals in a Pandemic
• Limit death and illness
• Preserve continuity of essential
government and business functions
• Minimize social disruption
• Minimize economic losses
Critical and Essential Services
•
•
•
•
•
•
Police & military
Fire & rescue
EMS & coroners
Electric & gas
Telephone & data nets
Media (TV, radio &
newspapers)
• Public Health
• Hospitals & clinics
•
•
•
•
•
Water System
Sewer System
Solid Waster (Trash)
Grocery & Drug Stores
Food manufacturers &
distribution system
• Fuel manufacturers &
distribution system
• Banks
What all organizations can do:
Maintain Essential Services
• Identify essential activities and redeploy staff if needed to fill vacancies
in critical services.
• Cross train: Make sure all critical
functions can be done by several
different people.
Maintain Essential Services
• Create written instructions/
procedures for critical processes that
can be carried out by others
• If possible, keep essential supplies/
parts stockpiled in advance to
maintain services.
Time Duration and “Waves”
• Ensure essential functions over a six-toeight-week pandemic wave?
• Ensure recovery from a first wave, while
preparing for possible subsequent waves
over the course of a calendar year?
• Define breaking points when a portion or
all basic and essential business functions
begin to fail?
Impacts to Law Enforcement:
• 25% - 35% of officers absent due to illness,
death, caring for family members
• 911 dispatch centers operating with reduced
staff, higher call volumes
• Large numbers of people unable to purchase
food, pay bills – high unemployment and
schools closed
• Potential for civil unrest over weeks / months
• Hospitals may become high security areas
• No mutual aid available
Impacts to Law Enforcement:
• What organizational functions would have to be altered in
the event of a pandemic?
• Impact on outside resources you depend on (vehicle
towing, jail capacity, hospital services, food vendors)
• Review the authority granted to LE to take action during a
health emergency.
• What vaccines and antiviral medications will LE personnel
and their families be offered
• What problems will LE leaders face if there is no vaccine
or medications are provided to LE and their families
• What orders will be lawful or unlawful in such
circumstances
Impacts to Law Enforcement:
• Critical priorities to be covered and determine alternative
mechanisms or work-around for addressing vital tasks
such as dispatch.
• What about the prisoners in your custody when jail staff is
reduced below safe operations?
• Enforcement of quarantine orders and other restrictions
and the escalation of force and the use of lethal force to
accomplish containment of disease.
• Vulnerable targets for crimes of opportunity and
fraudulent schemes (vacated schools, office complexes,
etc.) and special population groups (elderly).
Prepare for difficult HR issues
• If offices are closed, will staff be paid?
• If staff are needed, can they refuse to come to
work?
• If required to report, what protective equipment,
if any, will be provided?
• Can employer force someone who may be ill
NOT to work? (Employees without sick leave
may try to work while ill.)
• If an employee is required to work with ill people
and becomes ill, is it a worker’s comp situation?
Increase Social Distance
• Determine how to provide services
with less person-to-person contact
whenever possible
• Increase telecommuting if possible
• Use phone, web, virtual conferences
to replace face-to-face meetings
Provide Personal Protective
Equipment
• Need will vary with type organization
• Will be difficult to obtain in a pandemic
- need to secure in advance
• Masks (N95 or better) may reduce
exposure, but are difficult to wear for
prolonged time or if employee has
health problems.
Supply chain disruption
• Given widespread social disruption and
employee absenteeism, supply chains
may be interrupted.
• A pandemic will affect countries around
the world, with some regions hit earlier,
longer, and harder than others slowing
production of supplies.
What’s Realistic for Your
Organization?
•
•
•
•
•
•
Social Distancing
Stockpiling Supplies
Pay/Leave Policies
Essential Services/Functions
Security
Level of Authority and Enforcement
A Chronic Event
“Most of the COOP or disaster planning is
based on the assumption that it will be an
acute event…. It is not based on the idea
of chronic event.”
A pandemic could hit a city over a period of
four to six weeks…relent for awhile…and
then resume.
Comments & Questions
Thank You
Ricky Reeves, Division Chief
Lewisville Fire Department
[email protected]
Mike Megna, Retired
UTMB
[email protected]
Summer Wilhelm, CEM
City of Lewisville – Emergency Management
[email protected]