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Case Study: Pandemic Flu Scenario

January 11, 2007Newark, NJ

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

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New Jersey Preparedness Training Consortium

www.nj-ptc.org

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Ground RulesGround 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

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Rutgers Nursing Center for Bioterrorism & Emerging Infectious Diseases Preparedness Facilitators

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

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ObjectivesObjectives• 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!It’s There!

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BackgroundBackground

• 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.

June 2005June 2005

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BackgroundBackground

• 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.Source: WHO. June 16, 2005.

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What Makes a Pandemic? 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

Avian Influenza: The Virus

library.wur.nl/frontis/avian_influenza/

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Mortality Due to InfluenzaMortality 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

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Prophylaxis and Treatment of Influenza

Prophylaxis and Treatment of Influenza

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

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How Oseltamivir WorksHow Oseltamivir Works

Moscona A . NEJM 2005; 353:1363-73

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Lab Confirmed Cases of Human

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

Avian Flu as of February 21, 2006

Adapted from http://europa.eu.int/comm/health/ph_threats/com/Influenza/ai_current_en.htm. Accessed 5 March 2006

Case-Fatality Ratio (92/170 ~54%)

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Suspicious CaseSuspicious 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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InvestigationInvestigation

• 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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AlertAlert

• 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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AlertAlert

– 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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OutbreakOutbreak

• 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 UpdateSituation 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 UpdateSituation 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 ReportCasualty Report

July 2005July 2005

Cases Deaths

Vietnam 62 35

Laos 12 4

Thailand 17 12

Cambodia 4 4

Canada 6 1

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Coming and Going (1)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.

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

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Coming and Going (2)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 StatisticsSource: Bureau of Transportation Statistics

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Discussion 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!It’s Here!

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Local OutbreakLocal Outbreak

• 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.

August 2005August 2005

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SourceSource

• 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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SurgeSurge

• 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 StatusVaccine Status

• There is no vaccine available.

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Casualty ReportCasualty Report

August 2005August 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

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DiscussionDiscussion

• 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?

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Breathing RoomBreathing Room

CasesCases

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ImpactImpact

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

December 2005December 2005

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Casualty ReportCasualty ReportDecember 2005December 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

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End of First WaveEnd 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.

CasesCases

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Vaccine ArrivesVaccine Arrives

• Reaction is mixed– Fear of side effects– Demand greater than supply

• Shortages occur at all levels: International, national, state, local, organization

• Reaction is mixed– Fear of side effects– Demand greater than supply

• Shortages occur at all levels: International, national, state, local, organization

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OverseasOverseas

• Outbreaks continue abroad.

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

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PrioritizationPrioritization

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

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Psychosocial ImpactPsychosocial Impact

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

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VigilanceVigilance

• 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 TensionsPolitical 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 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!It’s Back!

CasesCases

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Second WaveSecond Wave

• Illness and death rates have crept back up again.

July 2006July 2006

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On the MoveOn 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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OvertimeOvertime

• 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 HiringNow 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.

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Respiratory InterventionRespiratory 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

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Surge CapacitySurge Capacity

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

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Surge Capacity QuestionSurge Capacity Question

• What is the surge capacity for your organization?

• Does it meet the required needs?

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Vaccination CampaignVaccination Campaign

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

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Casualty ReportCasualty Report

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

July 2006July 2006

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Discussion 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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ConclusionConclusion

• 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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Casualty ReportCasualty Report

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

December 2006December 2006

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Conclusion: Take-homeConclusion: Take-home

• Are we prepared to respond to pandemic flu?

• Individual• Local• Regional• National• International

• What steps are your agency taking to prepare?

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DisclaimerDisclaimer

• 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.

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Case Presentation 1Case 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

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Case Presentation 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

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Case Presentation 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

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Case Presentation 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

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Case Presentation 2Case 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

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Case PresentationCase 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

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Case PresentationCase 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

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Case PresentationCase 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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AcknowledgementsAcknowledgements

• 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

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Helpful Web SitesHelpful Web Sites

• http://bioterrorism.rutgers.edu/• www.cdc.gov• www.who.in/en/• www.fao.org• www.oie.org