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Case Study: Pandemic Flu Scenario January 11, 2007 Newark, NJ

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Title: Case Study: Pandemic Flu Scenario January 11, 2007 Newark, NJ


1
Case Study Pandemic Flu Scenario January 11,
2007Newark, 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
2
New Jersey Preparedness Training
Consortium www.nj-ptc.org
3
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

4
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

5
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.

6
Its There!
7
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.

8
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.
9
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 2005173869-70.
10
Avian Influenza The Virus
library.wur.nl/frontis/avian_influenza/
11
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
12
Prophylaxis and Treatment of Influenza
MMWR Morb Mort Wkly Ret. 200352(RR-8)1-36
13
How Oseltamivir Works
Moscona A . NEJM 2005 3531363-73
14
Lab Confirmed Cases of Human Avian Flu as of
February 21, 2006
Case-Fatality Ratio (92/170 54)
Adapted from http//europa.eu.int/comm/health/ph_t
hreats/com/Influenza/ai_current_en.htm. Accessed
5 March 2006
15
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.

16
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.

17
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.

18
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.

19
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.

20
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.

21
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.

22
Casualty Report
July 2005
Cases Deaths
Vietnam 62 35
Laos 12 4
Thailand 17 12
Cambodia 4 4
Canada 6 1
23
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.
24
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
25
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?

26
Its Here!
27
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.

28
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.

29
Surge
  • Local hospitals are seeing a surge of patients in
    emergency departments.
  • Political and health authorities are bombarded
    with questions about what to do.

30
Vaccine Status
  • There is no vaccine available.

31
Casualty Report
August 2005
Total Cases to Date Total Deaths to Date
Global 2,730 1,150
U.S. 750 231
New York 420 106
Canada 670 150
32
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?

33
Breathing Room

Cases
34
Impact
December 2005
  • The pandemic has not been stopped and the impact
    to date has been enormous

35
Casualty Report
December 2005
Total Cases to Date Total Deaths to Date
Global 322 million 7.7 million
U.S. 14.8 million 177,600
New York 950,000 11,400
New Jersey 350,000 4,500
Canada 1.6 million 19,680
36
End of First Wave
  • 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.

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

38
Overseas
  • Outbreaks continue abroad.
  • Poor countries on every continent are
    experiencing local, savaging outbreaks in remote
    regions and mega-cities alike.

39
Prioritization
  • Many advocate prioritizing the military for
    vaccine, medications, equipment, and medical
    personnel to maintain national security.

40
Psychosocial Impact
  • After months of steady outbreaks, few lives are
    untouched by illness, death, bereavement, and
    stress.

41
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.

42
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.

43
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?

44
Its Back!
Cases
45
Second Wave
July 2006
  • Illness and death rates have crept back up again.

46
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.

47
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.

48
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.

49
Respiratory Intervention
  • Assumptions
  • Anticipate gt 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

50
Surge Capacity
  • Auxiliary hospitals increase in size and number
    in temporary facilities and structures.

51
Surge Capacity Question
  • What is the surge capacity for your organization?
  • Does it meet the required needs?

52
Vaccination Campaign
  • Immunization levels average 35, with a range
    between 10 and 60.

53
Casualty Report
July 2006
Total Cases to Date Total Deaths to Date
Global 644 million 15.5 million
U.S. 29.6 million 355,200
New York 1.9 million 22,800
New Jersey 750,000 9,500
Canada 1.9 million 39,360
54
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?

55
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.

56
Casualty Report
December 2006
Total Cases Total Deaths
Global 967 million 23.2 million
U.S. 44 million 532,800
NY 2.9 million 34,200
NJ 1.5 million 18,500
Canada 4.9 million 59,040
57
Conclusion Take-home
  • Are we prepared to respond to pandemic flu?
  • Individual
  • Local
  • Regional
  • National
  • International
  • What steps are your agency taking to prepare?

58
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.

59
Case Presentation 1
  • 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

60
Case Presentation
  • Physical 40 y/o well developed ? in mild
    discomfort because of diarrhea and cough
  • BP110/70 P90 R 22 T101.9
  • 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

61
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

62
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

63
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

64
Case Presentation
  • Physical 65 y/o male in moderate discomfort
    because of shortness of breath and cough
  • BP160/92 P108 R 30 T101.9
  • 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

65
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

66
Case Presentation
  • Sputum is non specific for pathogens
  • Swab () for Influenza but nonspecific
  • Intake and Outake monitored.
  • Responds to diuretics and Tamiflu, (oseltamivir)

67
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

68
Helpful Web Sites
  • http//bioterrorism.rutgers.edu/
  • www.cdc.gov
  • www.who.in/en/
  • www.fao.org
  • www.oie.org
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