Georgias Pan Flu Planning for ESF 8, Assuring

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Georgias Pan Flu Planning for ESF 8, Assuring
Coordinating the Delivery of Patient Care

• PATRICK ONEAL, M.D.
• MEDICAL DIRECTOR
• OFFICE OF EMS/TRAUMA/EMERGENCY PREPAREDNESS
• With appreciation to Drs. Susan Lance and Cherie
  Drenzek for use of some of their slides

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Overview of Session

• Background
• Current situation worldwide
• Why so much concern?
• How would avian influenza impact us?
• How would a pandemic impact us?
• How can we be prepared?
• Current plans/infrastructure
• Overarching benefits

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Pan Flu Patient-Care Planning Our Basic
Assumptions

• We do not know when it will arrive
• We do not know whether it will look like the
  1918--or 1968 pandemic
• We cannot predict the severity
• We are asking everyone to prepare for the
  WORSTour lesson learned from Hurricane
  Katrinabut hope for the BEST

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Background Influenza Viruses

• Influenza viruses make mistakes when they
  replicate
• Results in changed viruses (antigenic drift
  and shift)
• Novel influenza A subtype in humans pandemic
• Influenza A viruses named by surface proteins
• Hemagglutinin (16)
• Neuraminidase (9)

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Seasonal, Avian, and Pandemic Influenza

• Seasonal influenza viruses (H3N2, H1N1, etc.)
• A public health problem every year
• Circulates throughout the human population
• Spread easily from person to person
• Avian influenza A (H5N1) (BIRD FLU)
• Devastating global outbreak in birds and poultry
• Severe but rare human infections
• Does not spread easily from person to person
• Pandemic influenza virus
• A brand new influenza A subtype that can infect
  humans
• Causes serious illness
• Spreads easily from human-to-human
• H5N1 is a likely candidate, but is not a pandemic
  virus yet

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Pandemic Strain Emergence Direct Infection
Avian virus
Avian Reservoir
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Pandemic Strain Emergence Reassortment of
Influenza A Viruses
Human virus
Avian virus
Avian Reservoir
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Current Situation Humans
Turkey Cases 12 Deaths 4
Azerbaijan Cases 8 Deaths 5
Lao (PDR) Cases 2 Deaths 2
China Cases 24 Deaths 15
Iraq Cases 3 Deaths 2
Nigeria Cases 1 Deaths 1
Vietnam Cases 93 Deaths 42
Egypt Cases 34 Deaths 14
Thailand Cases 25 Deaths 17
Cambodia Cases 7 Deaths 7
Djibouti Cases 1 Deaths 0
Indonesia Cases 81 Deaths 63
December 2003-April 11, 2007
TOTAL 291 cases, 172 deaths (59 mortality)
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Current Situation Birds
UNPRECEDENTED H5N1 OUTBREAK IN BIRDS
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Factors Associated with Human Disease

• Home preparation of sick poultry
• Contact with soil contaminated with feces of
  infected birds
• Cohabitation with sick birds
• Close contact with very ill family member

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Harbinger of Pandemic?Why so much concern?

• Largest and most severe bird outbreak in history
• Evidence of rare human to human transmission in
  Thailand and Indonesia
• H5N1 infection in domestic cats
• H5N1 evolution to two distinct genetic forms
  (clades)
• Mutation expressing resistance to Tamiflu (Egypt
  December, 2006)
• New H5N1 form in China

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Harbinger of Pandemic?Why so much concern?

• Widespread and spreading prevalence in migratory
  birds broad host range
• Continued outbreaks among domestic poultry
• Mammalian infection (cats, pigs, etc.) lethal
• Virus is evolving
• Sporadic human cases

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Harbinger of Pandemic?Why so much concern?

• Clinical features of avian influenza A (H5N1)
  infections in humans (very severe)
• Receptors deep in lung epithelia
• Persistent fever progressing to ARDS (hemorrhage
  in lungs) or secondary pneumonia
• Upper respiratory signs variable
• Marked lymphopenia predicts mortality
• Mortality rate gt50
• Implications for person-to-person transmission?

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Pan Flu Patient-Care Planning Our Basic
Assumptions

• Existing HCW shortages will not get better
• Limited Medical surge capacity
• About the Pandemic
• IF35 Attack Rate
• 3,000,000 total sick in GA
• Most Likely Scenario
• By week 6 almost 6,000 hospital admissions /
  week
• potentially OVERWHELMS all Medical Surge Capacity

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Historic Surge Capacity - 1918

• 1918-1919 Spanish Flu
• Type A virus (H1N1)
• 20-50 million deaths worldwide
• 500,000 US deaths
• Nearly half were young, healthy adults

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Social Impact of a Pandemic in Georgia
Assuming Georgia makes up 3 of US population,
9.1 million people
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Current Georgia Plans/Infrastructure

• Statewide Pandemic Coordinating Committee
  (multi-disciplinary)
• State Pandemic Management Team (Dr. Susan Lance)
• Georgia Pandemic Influenza Plan (HHS model)
• Pandemic Standard Operating Guide (Annex to EOP)
• Community Partner Planning Kits (Dennis Jones)
• County Pandemic Influenza Planning Committees
  (CPIPC)
• In-Home Case Management Plan
• Dept of Agriculture Poultry Industry Liaison
  (Dr. Dana Cole)
• Expand flu testing to Waycross GPHL
• Relationship with BENS
• Pandemic website (one-stop shopping)
• 2 Peachtree Go-Teams for SNS RSS (metro)
• Training (VICS, etc)
• Stay tuned

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In-Patient Surge Capacity Plan

• Existing Facilities
• 23,000 licensed beds
• 16,000 Real / Available beds
• ISC 1 2,000
• ISC 2 4,000
• ISC 3 6,000
• Alternative Care Centers
• 18 Portable Hospitals 900 beds (in progress)
• InHome Case Management

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InHome Case Management, OR our 3,000,000 Surge
Beds

• Seven Elements
• PSAs / Community Education
• Early Self-identification
• Telephone Registration/Triage
• Voluntary Isolation Quarantine at home
• Home Care Kits
• Care-giver education
• Community Support System

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InHome Care

• Home Care Kit
• Medications (as available)
• Thermometer
• Incentive Spirometer
• ???
• Care-giver education via PBS
• How to Care for a Patient with the Flu
• Daily follow-up triage calls
• Coordination with Community Support services

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Protecting Humans Masks?

• Some experiments with influenza viruses (not
  H5N1) show aerosol route to be important in
  person-to-person transmission
• However, recent evidence (Lancet, April 2007)
  reiterates that droplet transmission most
  important (short distances)
• Masks integral in stopping transmission
• N95 best (brands vary), surgical good?
• Implications for planning?
• Supplies limited!

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• Any local government that fails to prepare for
  an Influenza Pandemic, expecting the federal or
  state government to bail them out will be
  tragically wrong.
• Michael Leavitt
• Secretary of Health Human Services

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Federal Planning
Don't count on federal rescue White House says
local communities must prepare for pandemic
disruptions
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Pandemic Influenza Planning Kits

• County Pandemic Influenza Planning Committee
  (CPIPC)
• Community Organizations
• Faith Based Organizations
• Key Service Businesses
• Outpatient Providers
• Media
• Businesses
• Schools
• Transportation Systems
• Government Agencies

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The Role of the CPIPC

• Identify all of the organizations in the
  community
• Determine the best way to communicate with the
  organizations
• Help each organization PLAN how IT will prepare
• Coordinate all of the plans

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Segments of Society to include in CPIPC

• Government
• Public Health
• Healthcare
• Media
• Business
• Schools
• Transportation
• Community Organizations
• Faith-based organizations
• General Public

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Step 3 How would a pandemic influenza strain in
Georgia impact us?

• Months-long waves of illness
• Essential services like food, energy, healthcare
  disrupted
• Medical response will be limited, strained, or
  depleted
• Economic impact devastating
• Up to 40 of workforce sick for months
• No unaffected communities or federal resources to
  help
• Focus on localities individual citizens

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Step 3 How would a pandemic influenza strain in
Georgia impact us?

• Limited/delayed availability of vaccine
• Prioritization of vaccine
• Limited availability of antivirals
• Focus on in-home care (dont go to hospital!)
• Community-level social distancing measures
• Not working or teleworking
• School closures
• No mass gatherings?

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What does Pandemic Preparedness Entail?

• Not an endpoint, but a journey
• Flexibility
• Infrastructure
• Relationships
• Money

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Other Lingering, Challenging Questions

• What is our own continuity plan?
• Is stockpiling a good idea? Which antiviral?
• When will there be a vaccine?
• Vaccine research shows 50 efficacy
• Role of cats
• Risk of waterborne transmission
• Containment measures
• Logistics and legalities of social distancing
  quarantine?
• When should school closures occur?
• How will chaos affect containment measures?
• Cooperation of society?
• Will essential goods services be available?
• Many, many more

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And if we succeed..

• We CANNOT stop the Pandemic
• We CAN
• Delay the Epi Curve
• Diminish the peak impact on Healthcare Resources
• Decrease overall impact on society

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How far along are we in GA?

• Bioterrorism preparedness for gt5yrs
• Surveillance enhancements (birds, people)
• Education campaign
• Health District needs assessment/plans
• Antiviral stockpile (1.3 million courses)
• Hospital preparedness
• Decontamination, PPE, isolation units
• Surge capacity
• 4,000 portable hospital beds
• Cache of portable ventilators, 460,000 N-95 masks

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Resources

• www.cdc.gov
• U.S. public health guidelines
• www.pandemicflu.gov
• HHS pandemic plan
• www.who.int
• Global updates and official case reports
• www.health.state.ga.us
• GA pandemic plan

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Questions Answers
www.health.state.ga.us
PATRICK ONEAL, M.D. jponeal_at_dhr.state.ga.us 404-4
63-5419