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Community Challenge of Pandemic Influenza. Michael P. Dailey, M.D., FACP North Fulton Regional Hospital Roswell, GA. Pandemic Influenza. Bird Flu Strikes Florida. The Question. Why worry about pandemic influenza?. The Answer. Flu Terms. Seasonal flu – influenza like illness year to year

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Community challenge of pandemic influenza

Community Challenge of Pandemic Influenza

Michael P. Dailey, M.D., FACP

North Fulton Regional Hospital

Roswell, GA




The question
The Question

  • Why worry about pandemic influenza?



Flu terms
Flu Terms

  • Seasonal flu – influenza like illness year to year

  • Avian flu (AI) – low pathogenicity in birds is common

  • H5N1 – highly pathogenic AI, deadly to domestic fowl and transmissible to humans

  • Pandemic flu – virulent human flu that causes global outbreak with little natural immunity


Diagnosis
Diagnosis

  • During influenza season, influenza like illness with cough and fever can be presumed to be influenza

    Monto et al Arch Int Med 2000;160:3243-3247


H5N1

  • Hong Kong 1997

    -cluster of human cases associated with poultry

    Claas et al Lancet 1998;351:472

  • Southeast Asia 2003

    -outbreaks in 8 Asian countries

    Ungchusak et al NEJM 2005;352:333

  • Indonesia 2005

    -human clustering

    Kandun et al NEJM 2006;355:2186


H5N1

  • Turkey 2006

  • Great Britain 2007

  • As of February 6, 2007

    • Total human cases 272

    • Deaths 166

    • Mortality 61%


Maa initiative 2006
MAA Initiative 2006

  • John Harvey, M.D.

  • Matt Gwynne, M.D.

  • Radio Sandy Springs Interviews

    • September 11, 2006 – December 18, 2006

    • Archived

    • www.radiosandysprings.com

    • 7pm Monday

    • MAA Pandemic Flu Report, January 24, 2007


Summary of findings
Summary of Findings

Medical Care Groups

  • Critical A

    • Patients with respiratory failure due to viral or bacterial pneumonia

  • Critical B

    • Identical patients for whom no ventilator support is available

  • Urgent

    • Patients requiring hydration or IV antibiotics and anti-emetics who could be sent home

  • Basic

    • Uncomplicated influenza needing advice and/or antivirals, but neither critical nor urgent care


  • Summary of findings1
    Summary of Findings

    The central issue for pandemic healthcare is how to respond to the loss of our most critical asset, the hospital.

    How do we evaluate care needs in such a circumstance?



    Summary of findings2
    Summary of Findings

    • Evaluation of Roswell/Alpharetta

      • Population 150,000

      • Mortality 1%

      • Infected patients 45,000

      • Deaths 450


    Summary of findings3
    Summary of Findings

    • Evaluation of Roswell/Alpharetta

      • Deaths 450

      • Critical care pts. 450 x 2 = 900

      • Potential hospitalized 450 (50%)

      • Ventilator needs 450 (over 3 mos.)

      • Ventilators available 50

      • Patients saved by critical care 25


    Hydration and influenza
    Hydration and Influenza

    • Dehydration common due to poor fluid intake, fever and rapid mouth breathing

      Hosker et al BMJ 1994; 308:701

    • Dehydration and GI dysfunction

      VanNieuwenhoven et al Eur J App Phys 2000;83:578

    • Airway dehydration and asthma

      Maloney et al Chest 2002;121:1806

    • Dehydration related abdominal pain

      Shah et al J Coll Physicians Surg Pak 2004;14:14

    Dehydration and/or renal dysfunction occurs on 24 to 35% of hospital admissions for influenza


    Summary of findings4
    Summary of Findings

    • Evaluation of Roswell/Alpharetta

      • Urgent care pts. = 1% of infected 450

      • Mortality in urgent care 20%

      • Potential urgent care save = 360

    Save 360 with urgent care vs.

    25 by critical care (i.e. > 10:1)


    Summary and conclusions
    Summary and Conclusions

    • Fulton County plan is based on hospital being open – the reality is otherwise

    • The hospital will experience 30-50% staff deficiencies during pandemic

    • We will need a voluntary plan to provide urgent care at off campus sites

    • We will need a community committee to develop urgent care plans including MD, hospital, EMS, and city government input


    Pandemic urgent care
    Pandemic Urgent Care

    • Fluids – 1 liter of NS

    • IV antibiotics

      • Ceftriaxone 2 Gm (Rocephin)

      • Ertapenem 1 Gm (Invanz) if Pen allergic

  • Antiemetic

    • Phenergan 12.5 mg

  • Allergy Kit

    • Antihistamine

    • Steroid

    • Epipen

  • Pulse Oximetry


  • Problems
    Problems

    • Where will my neighborhood get care?

    • How will they know where to go?

    • Who will give it to them?

    • Who will provide logistic support?


    Vaccine
    Vaccine

    • “Barricade vaccine”

    • “Rampart vaccine”

      • ED Kilbourne Viral Immunol 2004;17:350

  • H5N1 Clade 1

  • H5N1 Clade 2 – 3 subclades

    • Cross protection against death in ferrets

    • Govorkova et al JID 2006;194:159


  • Call to action
    Call to Action

    • We will need a community committee to develop urgent care plans including MD, hospital, EMS, and city government representation

    • We will need you to provide the care in your community that will make the most difference

    • It will not be in the hospital


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