“force protection” during a pandemic influenza

“Force Protection”During a Pandemic Influenza

Ricky Reeves, Division Chief, Lewisville FireCatastrophic Guidelines and Triage Subcommittee

Mike Megna, Retired, UTMBCatastrophic Guidelines and Triage Subcommittee

Summer Wilhelm, CEM, City of Lewisville

Texas Division of Emergency Management Conference 2012

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

IncubationIncubation Symptomatic (Sick)Symptomatic (Sick) RecoveringRecovering

Work, etc. Work/Home/Hospital Back to work, etcDay 0 Day 11Day 4 Day 15

DANGER OF INFECTION

Day 2

Infectious (Shedding Virus)Infectious (Shedding Virus)

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 AboutPandemic Influenza?

• Influenza pandemics are inevitable; naturally recur at more or less cyclical intervals.

• The pandemic flu clock is ticking, we just don’t know what time it is.

• Experts: predict the next “big one” is H5N1, it is inevitable….

• Other experts: It may happen now, or over the next several years….

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

H7H5H9*

1980

1997

Recorded new avian influenzas

1996 2002

1999

2003

1955 1965 1975 1985 1995 2005

H1N1

H2N2

1889Russian

influenzaH2N2

H2N2

1957Asian

influenzaH2N2

H3N2

1968Hong Konginfluenza

H3N2

H3N8

1900Old Hong

Kong influenza

H3N8

1918Spanishinfluenza

H1N1

1915 1925 1955 1965 1975 1985 1995 20051895 1905 2010 2015

2009Pandemicinfluenza

H1N1

Recorded human pandemic influenza(early sub-types inferred)

Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus Research, National Institute of Infectious Diseases (NIID), Japan.

Animated slide: Press space bar

H1N1Pandemic

H1N1

Impact of Past Influenza Pandemics/Antigenic Shifts in US

Pandemic, or Antigenic Shift

Excess Mortality Populations Affected

1918-19(A/H1N1)

650,000 Persons <65 years

1957-58(A/H2N2)

70,000 Infants, elderly

1968-69(A/H3N2)

36,000 Infants, elderly

1977-78(A/H1N1)

8,300 Young (persons

<20)

2009(A/H1N1)

12000 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

0

100

200

300

400

500

600

700

800

900

Civil WWI 1918-19 WWII Korean Vietnam War on

War Influenza War War Terror

Thousands

Minor Pandemic: Historical Clues

1957: Asian Flu

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

February: New strain H2N2 identifiedLittle prior immunityReassortant mutation (avian/human)Minor pandemicMay: Vaccine production beginsJune: Hits U.S. border quietly

Worldwide Spread in 6 MonthsWorldwide Spread in 6 Months

69,800 deaths (U.S.)69,800 deaths (U.S.)

Spread of H2N2 Influenza in 1957“Asian Flu”

Spread of H2N2 Influenza in 1957“Asian Flu”

Feb-Mar 1957Apr-May 1957Jun-Jul-Aug 1957

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: Southeast Asia: Prime pandemic mediaPrime pandemic media

--Agricultural practicesAgricultural practices-Cultural practices-Cultural practices-Proximity: -Proximity: Human, bird, swineHuman, bird, swine Chance for reassortmentChance for reassortment-Virus amplification with -Virus amplification with poultry outbreak!!!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

Interpandemic

Larger clusters, localized

Limited spread among humans

Pandemic

Current Status

Pandemic alert

Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6

New virus in

humans

Little/no spread among humans

Small clusters, localized

Limited spread among humans

Increased and

sustained spread in general human

population

No new virus in humans

Animal viruses low risk

to humans

No new virus in humans

Animal viruses low risk

to humans

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???

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

Pandemic Flu Today

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 immune-compromised 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

Schools

Households

Work place

Likely Sites of Transmission

Children/Teenagers 26.97%

Adults 59.99%

Seniors 13.04%

Demographics (2010)

A Typical Family’s Day

Carpool

HomeHome

Work Lunch WorkCarpool

Bus

Shopping

Car

Daycare

Car

School

time

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

HomeHome

Force Protection

All services performed, provided, or arranged to promote, improve, conserve, or restore the mental or physical well-being 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 non-pharmaceutical countermeasures to EMS and9-1-1 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 ProtectionStaffing 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 ProtectionCost 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 ProtectionPlanning 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 re-deploy 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-to- eight-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 ChiefLewisville Fire Departmentrreeves@cityoflewisville.com

Mike Megna, RetiredUTMBmmegna@sbcglobal.net

Summer Wilhelm, CEMCity of Lewisville – Emergency Managementswilhelm@cityoflewisville.com