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Influenza: Is This an Emergency?. Mike McEvoy, PhD, REMT-P, RN, CCRN EMS Coordinator, Saratoga County, NY EMS Director - NYS Association of Fire Chiefs Clinician & Instructor - Critical Care Medicine and Cardiothoracic Surgery, Albany Medical College. Disclosures.

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slide1

Influenza:Is This an Emergency?

Mike McEvoy, PhD, REMT-P, RN, CCRN

EMS Coordinator, Saratoga County, NY

EMS Director - NYS Association of Fire Chiefs

Clinician & Instructor - Critical Care Medicine and Cardiothoracic Surgery, Albany Medical College

disclosures
Disclosures
  • I have no financial relationships to disclose.
  • I serve on advisory boards and work as a paid pandemic planning consultant.
  • I am the EMS technical editor for Fire Engineering magazine.
  • I do not intend to discuss any unlabeled or unapproved uses of drugs or products.
poll question 1
Poll Question # 1

What is your primary role?

  • EMS
  • Fire
  • Law Enforcement
  • Nurse
  • Physician
outline
Outline
  • The current H1N1 problem
    • Separating fact from fiction
  • What is influenza?
  • Public safety implications
  • What you need to do
    • Personally
    • Professionally
h1n1 what s the situation
H1N1: What’s the situation?
  • 12 April Mexico Government requests WHO assistance with outbreak of acute respiratory infections in La Gloria, Veracruz
    • population 2155; 616 = 28.5% ill
  • 23 April, CDC describes 5 cases of novel influenza virus (A/H1N1/North America/Human)
    • 3 from San Diego area, 2 from San Antonio, TX

WHO Weekly Epidemiological Record. 23; 2009, 84:213-219

h1n1 what s the situation1
H1N1: What’s the situation?
  • 12 April Mexico Government requests WHO assistance with outbreak of acute respiratory infections in La Gloria, Veracruz
    • population 2155; 616 = 28.5% ill
  • 23 April, CDC describes 5 cases of novel influenza virus (A/H1N1/North America/Human)
    • 3 from San Diego area, 2 from San Antonio, TX
  • Subsequent WHO surveillance indicated a respiratory outbreak in Central Mexico, including Mexico City, for previous 3 weeks
    • 1 March-29 May = 41,998 acute respiratory infections
    • 5,337 (12.7%) cases confirmed new A/H1N1 flu
    • 97 deaths, mostly in young adults (20-45 years old)
    • Outbreak peaked nationally in late April
    • Localized cases continue to be identified
    • As of 29 May, Mexico City highest # cases/deaths (1804/38)

WHO Weekly Epidemiological Record. 23; 2009, 84:213-219

novel h1n1 spread
Novel H1N1 Spread…

11 June 2009 totals:

28,774 cases, 144 deaths

what is h1n1 a k a swine flu
What is H1N1 (a.k.a. “Swine”) flu?
  • H1N1 is a respiratory disease of pigs caused by type A flu virus; first isolated in 1930
  • Circulates year round;  during flu season
  • High rates of illness, low death rates in pigs
what is h1n1 a k a swine flu1
What is H1N1 (a.k.a. “Swine”) flu?
  • H1N1 is a respiratory disease of pigs caused by type A flu virus; first isolated in 1930
  • Circulates year round;  during flu season
  • High rates of illness, low death rates in pigs
  • The 2009 human flu outbreak is a new strain of H1N1 influenza never isolated in swine (origin unknown)
  • Pigs are very susceptible to infection from humans
h1n1 the facts
H1N1: the facts
  • Apparently easy human-to-human spread; ability attributed to (as-yet) unidentified mutation
h1n1 the facts1
H1N1: the facts
  • Apparently easy human-to-human spread; ability attributed to (as-yet) unidentified mutation
  • Most cases have only mild symptoms; infected people make full recovery without medical attention and without antiviral meds
  • World Health Organization (WHO) stated that symptoms appear less severe than seasonal influenza
swine were victimized
Swine were victimized
  • NA swine
  • European swine
  • Avian
  • Human

Novel A/H1N1 virus

swine were victimized1
Swine were victimized
  • NA swine
  • European swine
  • Avian
  • Human
  • Some nations began culling pigs!

Novel A/H1N1 virus

u s response
U.S. Response
  • CDC: notified clinicians, issued guidance
  • Public Health Emergency declared
    • Allowed release of funds
    • ¼ SNS pushed to states (Rx, N-95s)
u s response1
U.S. Response
  • CDC: notified clinicians, issued guidance
  • Public Health Emergency declared
    • Allowed release of funds
    • ¼ SNS pushed to states (Rx, N-95s)
  • Laboratory testing
    • Test kits developed for State labs
    • Sensitivity to Oseltamivir (Tamiflu®) & Zanamivir (Relenza®)
  • States charged to direct local actions…
  • Vaccine development begun
poll question 2
Poll Question #2

Will H1N1 be worse this fall?

will it get worse
Will it get worse?

“The only thing predictable about influenza is unpredictability.”

influenza
Influenza
  • Respiratory infection
  • Transmission: Contact with respiratory secretions from an infected person who is coughing and sneezing
  • Incubation period:1 to 5 days from exposure to onset of symptoms (typical 2 days)
  • Communicability:Maximum 1-2 days before to 4-5 days after onset of symptoms (kids > 10 days and possibly up to 6 months)
  • Timing:Peak usually December - March (NA)
poll question 3
Poll Question #3

Are you able to distinguish flu from a common cold?

influenza symptoms
Influenza Symptoms
  • Rapid onset of:
    • Fever
    • Chills
    • Body aches
    • Sore throat
    • Non-productive cough
    • Runny nose
    • Headache
influenza symptoms1
Influenza Symptoms
  • Rapid onset of:
    • Fever
    • Chills
    • Body aches
    • Sore throat
    • Non-productive cough
    • Runny nose
    • Headache
  • Hallmark = sudden onset
how you get the flu
How you get the flu:
  • Germs are transmitted
  • Infectious 1-2* days before and 4-5 days after symptoms appear
  • Greatest periodof infectioncorrelates withfever

*H1N1 may be 7 days

how close is too close
How close is too close?

Danger area around sick people is 3 feet

germs are transmitted nose hand object
Germs are transmitted:Nose  Hand  Object
  • Doorknob
  • Telephone
  • Radio mic
  • Pens
  • Keyboard
  • Dishes
  • Etc…
influenza viruses
Influenza Viruses
  • Hard non-porous surfaces 24-48°
    • Plastic, stainless steel, etc.
  • Cloth, paper & tissue 8-12°
    • Transferable to hands for 15 minutes
  • Hands  viable for < 5 min
  •  temp,  humidity =  survival
influenza is a serious illness
Influenza is a serious illness
  • Annual deaths (US): 36,000*
  • Hospitalizations: >200,000*

* 1990’s estimates from average 500 million annual cases

(Worldwide death rate > 250,000 annually)

influenza is a serious illness1
Influenza is a serious illness
  • Annual deaths (US): 36,000*
  • Hospitalizations: >200,000*

* 1990’s estimates from average 500 million annual cases

(Worldwide death rate > 250,000 annually)

  • Who is at greatest risk for serious complications?
    • persons 65 and older (comprise 85% of deaths)
    • persons with chronic diseases
    • infants
    • pregnant women
    • nursing home residents (attack rates of 60% vs. general population attack rates of 5-20%)
poll question 4
Poll Question #4

Did you get a flu vaccine last year?

vaccines

Vaccines

Protect people:

  • Those vaccinated (somewhat)
  • Family members/contacts (more)
  • 22 diseases (US)
  • >60,000 die annually from preventable diseases
take home points flu shot
Take Home Points: Flu Shot
  • Employers must offer for free
  • Just because you never get sick
    • Does not mean you don’t infect family
    • Does not mean you don’t infect patients
take home points flu shot1
Take Home Points: Flu Shot
  • Employers must offer for free
  • Just because you never get sick
    • Does not mean you don’t infect family
    • Does not mean you don’t infect patients
  • Unvaccinated HCW are negligent
influenza virus
Influenza Virus
  • Orthomyxoviridaesingle strand RNA respiratory viruses
  • Type A (most severe, 2 subtypes)
    • Humans, birds (avian)*, pigs (swine), horses (equine), other animals. * wild birds are natural hosts
    • Affects all ages
    • Epidemics and pandemics
  • Type B (less severe, no subtypes)
    • Humans only
    • Primarily affects children (can be severe in elderly)
    • Milder epidemics, cannot cause pandemics
  • Type C (mild to no symptoms)
    • Humans and pigs (swine)
    • Rare (?) - by age 15, most have antibodies
influenza a subtypes
Influenza A - subtypes

HA

(hemagglutinin)

15 types

(H5, H7, H9)

NA

(neuraminidase)

9 types

(N1, N2)

how flu viruses change
How Flu Viruses Change
  • Antigenic Drift:
    • Small changes in the virus over time
    • New strains appear and replace older strains
    • Antibodies to older strains may not work
  • Antigenic Shift:
    • Abrupt, major change
    • Results in novel strain or new subtype
    • Pandemic potential
slide44

Timeline of Emergence of

Influenza A Viruses in Humans

Avian

Influenza

H9

H7

Russian

Influenza

H5

H5

H1

Asian

Influenza

H3

Spanish

Influenza

H2

Hong Kong

Influenza

H1

1918

1957

1968

1977

1997

2003

1998/9

what is a pandemic
What is a Pandemic ?
  • Global outbreak with:
    • Novel (new) virus, all or most susceptible
    • Easily transmissible from person to person (newvirus – few would be immune)
    • Wide geographic spread (many would get sick worldwide)
what is a pandemic1
What is a Pandemic ?
  • Global outbreak with:
    • Novel (new) virus, all or most susceptible
    • Easily transmissible from person to person (newvirus – few would be immune)
    • Wide geographic spread (many would get sick worldwide)

Kill a lot of people (not just make them sick)

flu pandemics 20 th century
Flu Pandemics 20th Century

1968:

“Hong Kong Flu”

1957:

“Asian Flu”

1918:

“Spanish Flu”

A(H3N2)*

A(H2N2)

A(H1N1)

1-4 m deaths

70,000 US deaths

20-40 m deaths

>675,000 US deaths

1-4 m deaths

34,000 US deaths

influenza epidemiology
Influenza Epidemiology
  • Viruses normally species specific
  • “Spill over” extremely rare
bird flu h5n1 avian flu
Bird Flu: H5N1 Avian Flu

Type A flu has been:

  • In Waterfowl for 105 million years
    • Asymptomatic intestinal infection, all subtypes, excreted in bodies of water
  • In Domestic birds for 50 million years
    • Respiratory infection or illness, shed GI and respiratory fluids, may become very ill or die
avian influenza
Avian Influenza
  • Avian Flu type based ongenetic features and/orseverity of disease inpoultry
    • Low pathogenic AI (LPAI) = weak type
      • H1 to H15 subtypes
    • Highly pathogenic AI (HPAI) = strong type
      • Some H5 or H7 subtypes
avian influenza1
Avian Influenza
  • Highly pathogenic H5N1 influenza virus now endemic among bird and poultry populations in Asia
pattern change
Pattern Change?
  • Prior to H5N1, outbreaks of highly pathogenic flu in poultry rare
  • Most have had little geographic spread
  • Only one previously spread internationally
epidemiology not precise
Epidemiology not precise:

Spring 2007 –

East Coast

Fall 2006 –

Alaska, West Coast

human transmission
Human Transmission
  • Of hundreds of bird flu viruses, only 4 have infected humans:
    • H5N1, H7N3, H7N7, and H9N2
    • Except H5N1, very mild/limited illnesses
  • H5N1 remains largely a disease of birds:
    • Tens of millions of poultry infected since 2003 with fewer than 300 human cases
    • However, human case fatality rate 1997 – 2007 was 0.45
march 1 1947
March 1, 1947
  • Cross-country bus arrives from Mexico
  • Mr. and Mrs. Eugene Le Bar stay in NYC, en route to Maine
  • Couple explore the city (5th Ave)
  • Mr. Le Bar, feeling ill, rests in a midtown hotel (fever & rash)
summary 1 mar 21 apr
Summary: 1 Mar – 21 Apr
  • One case smallpox arrives NYC
  • 12 others infected:
    • 4 initially (2½ weeks later)
    • 8 in second wave (5 weeks later)
  • 2 die (index case and wife HCW)
  • 6,350,000 people vaccinated
  • 9 other deaths from vaccinations
summary
Summary
  • One case smallpox arrives NYC.
  • 12 others infected:
    • 4 initially (2½ weeks later).
    • 8 in second wave (5 weeks later).
  • 2 die (index case and wife HCW).
  • 6,350,000 people vaccinated.
  • 9 other deaths from vaccinations.

No HCW were infected.

summary1
Summary
  • One case smallpox arrives NYC.
  • 12 others infected:
    • 4 initially (2½ weeks later).
    • 8 in second wave (5 weeks later).
  • 2 die (index case and wife HCW).
  • 6,350,000 people vaccinated.
  • 9 other deaths from vaccinations.

No HCW were infected.

Why?

toronto ems spring 2003
Toronto EMS – Spring 2003
  • 41 Stations
  • 95 units/shift (180,000 transports/yr)
  • 850 medics
  • Over 400 medics quarantined for unprotected SARS exposures
  • 4 actually infected w/ SARS
  • Crippled 911 system
is this just an ems problem
Is this JUST an EMS Problem?
  • Most certainly NOT!
  • Total deaths worldwide from SARS: 916 (of total 8,422 cases reported from Nov 2002 through Aug 2003)
  • 25 % of deaths were HCWs (Health Care Workers). Fully one-quarter of SARS infections were HCWs.
  • Reason? Breaks in infection control procedures!
tasmania australia ems
Tasmania, Australia EMS
  • 10 ambulance officers isolated (15% of force) H1N1
  • 4 June 2009
tasmania australia ems1
Tasmania, Australia EMS
  • 10 ambulance officers isolated (15% of force) H1N1
  • 4 June 2009
  • “If people don’t take it seriously, this sort of thing will happen…”
show me the money
Show me the money…

HCW non-adherence w/ PPE recommendations:

  • Believe not necessary, inconvenient, disruptive
  • Lack of PPE availability
  • Inadequate infection control training
  • Lack of systematic HCW safety approach
  • Failure to recognize need (situational)

Daugherty et al. Crit Care Med 2009;37:1210-6

Swaminathan et al. Emerg Infect Dis 2007;13:1541-7

Visentin et al. CJEM 2009;11:44-56

symptoms of sars reported at hospital admission with symptom at admission n 144
Symptoms of SARS Reported at Hospital Admission ( % with symptom at admission, N=144)

JAMA, June 4, 2003 – Vol 289, No. 21 (SARS in the Greater Toronto Area)

infection key
Infection Key:
  • High Fever

> 100° F

poll question 5
Poll Question #5

Does your 911 center question callers about severe respiratory illness?

measuring temperature1
Measuring Temperature

Prehospital – in the field

  • Patient opinion
severe respiratory illness
Severe Respiratory Illness

What supplies do you need?

essential germ gear
Essential germ gear:
  • Isolation mask for the patient
      • Not N-95
      • Place over oxygen delivery device
      • Mask first, questions later
other germ gear
Other germ gear:
  • Gloves
  • N95 or better mask*
  • Goggles
  • Isolation gown
  • Hand cleanser
  • Disposables

* N-95 masks should be fit tested

gloves1
Gloves

For people, not equipment

first rule of infection control
First Rule of Infection Control

Wash your hands!

  • Alcohol based hand rubs
    • Superior (CDC, October 25, 2002)
  • Soap & water when dirty
second rule of infection control
Second Rule of Infection Control

Stay Away!

  • Limit providers and equipment @ scene
  • Limit providers during transport
infection control strategies
Infection Control Strategies
  • Social distancing
    • self-shielding
  • Cancel public events
    • movies, church, etc.
  • Close schools and work
    • offices, shopping malls
  • Close of rec facilities
    • pools, youth clubs, gyms
  • Respiratory/hand hygiene
  • Stay home if ill (self-report)
  • Active screening
    • send ill home (masked)
    • decon area
hospital ventilators
Hospital Ventilators
  • 105,000 ventilators in US (2006)
  • Normally ¾ in use
  • Typical flu season: 100% in use
antiviral medications
Antiviral Medications
  • Uses
    • Prophylaxis (prevention)
    • Treatment
  • Issues
    • Limited supply
    • Need for prioritization (among risk groups and prophylaxis versus treatment)
    • Unlikely to markedly affect course of pandemic
  • SNS (Strategic National Stockpile)
    • Presently ~ 81 million doses
  • Private sector
    • Up to 1.5 million doses stockpiled
pandemic vaccine
Pandemic Vaccine
  • Production using current technologies would likely take 4-5 months  may not be available before 1st pandemic wave
  • US mfg capability = 5 million doses/week
  • Implication: < 2% population protected per week
more about masks
More About Masks
  • Benefit of wearing masks by well persons in public settings has not been established
    • Persons may choose to wear a mask:
      • Keep hands away from your face!
      • Clean hands if you touch your mask!
what to advise the public
What to advise the public:
  • Wash your hands
  • Cover your cough
  • If you’re sick, stay home
  • Be prepared:
    • Get a flu shot every year
    • Stay rested and eat a healthy diet
    • Keep supplies on hand for self & family
h1n1 lessons
H1N1 Lessons:
  • Pandemic plans/supplies lacking
  • Little means of communicating
    • Within departments (leaders to members)
    • Between Public Health and anyone else
  • We have not been watching pigs
  • EMS providers still feel immune
leaders chiefs dept heads
Leaders, Chiefs, Dept. Heads:
  • Notify all members & staff pronto
  • Review pandemic plans
    • www.pandemicflu.gov/plan/ - checklists
  • Distribute info (email and web)
  • Get accurate, timely info
    • www.cdc.gov/h1n1flu/whatsnew.htm - up to the minute info from CDC
    • www.who.int – World Health Organization
ff ems leos
FF, EMS, LEOs:
  • Know what your walking into!
  • Interview from 6’ to determine PPE
  • Mask first if suspected resp illness
    • Avoid droplet-producing procedures
    • Alert hospital and hold patient
    • Decon – CDC interim guidelines: www.pandemicflu.gov/plan/healthcare/cleaning_ems.html
poll question 6
Poll Question #6

How did your agency do with the H1N1 outbreak?

  • Horribly
  • So so
  • Okay
  • Exceptional
take home messages
Take-home messages
  • Information is currency. Know the facts!
take home messages1
Take-home messages
  • Start now:
  • Wash your hands
  • Cover your cough
  • Gather supplies
  • Get a flu shot
  • Learn the plan
take home messages2
Take-home messages
  • Don’t panic
thanks for your attention
Thanks for your attention!

Slides posted at mikemcevoy.com