“Force Protection” During a Pandemic Influenza

1. Texas Division of Emergency Management Conference 2012 “Force Protection”During a Pandemic Influenza Ricky Reeves, Division Chief, Lewisville Fire Catastrophic Guidelines and Triage Subcommittee Mike Megna, Retired, UTMB Catastrophic Guidelines and Triage Subcommittee Summer Wilhelm, CEM, City of Lewisville

2. 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

3. DANGER OF INFECTION Infectious (Shedding Virus) Recovering Incubation Symptomatic (Sick) Work, etc. Work/Home/Hospital Back to work, etc Day 0 Day 2 Day 4 Day 11 Day 15 The Flu Virus as a Contagion

4. 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 twoof the three today.

5. 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.

6. Why the Concern AboutPandemic Influenza? • Influenza pandemics are inevitable; • naturally recur at more or less cyclical • intervals. • Experts: predict the next “big one” is H5N1, it is inevitable…. • Other experts: It may happen now, or over the next several years…. • The pandemic flu clock is ticking, we • just don’t know what time it is.

7. Influenza: The Flu Cycle

8. Pandemic influenza: definition • Global outbreak with: • Novel virus, all or most susceptible • Transmissible from person to person • Wide geographic spread

9. 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.

10. H3N8 H2N2 H2N2 H1N1 PandemicH1N1 H3N2 2015 2010 1915 1925 1955 1965 1975 1985 1995 2005 1895 1905 H1N1 H9* Recorded new avian influenzas 1999 H5 1997 2003 H7 1980 1996 2002 1955 1965 1975 1985 1995 2005 Pandemics of influenza Recorded human pandemic influenza(early sub-types inferred) 2009 Pandemic influenza H1N1 1889 Russian influenza H2N2 1968 Hong Kong influenza H3N2 1918 Spanish influenza H1N1 1900 Old Hong Kong influenza H3N8 1957 Asian influenza H2N2 Animated slide: Press space bar Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus Research, National Institute of Infectious Diseases (NIID), Japan.

11. Impact of Past Influenza Pandemics/Antigenic Shifts in US

12. The 1918 Influenza Pandemic

13. 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.

14. America’s deaths from influenza were greater than the number of U.S. servicemen killed in any war Thousands Civil WWI 1918-19 WWII Korean Vietnam War on War Influenza War War Terror

18. Minor Pandemic: Historical Clues 1957: Asian Flu February: New strain H2N2 identified Little prior immunity Reassortant mutation (avian/human) Minor pandemic May: Vaccine production begins June: Hits U.S. border quietly • 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

20. Worldwide Spread in 6 Months Spread of H2N2 Influenza in 1957“Asian Flu” Feb-Mar 1957Apr-May 1957Jun-Jul-Aug 1957 69,800 deaths (U.S.)

21. 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

24. Avian Influenza Today: Asia Southeast Asia: Prime pandemic media -Agricultural practices -Cultural practices -Proximity: Human, bird, swine Chance for reassortment -Virus amplification with poultry outbreak!!!

25. 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

26. Current Status Interpandemic Pandemic alert Pandemic Phase 4 Phase1 Phase 2 Phase 3 Larger clusters, localized Limited spread among humans Phase 5 Phase 6 No new virus in humans Animal viruses low risk to humans No new virus in humans Animal viruses low risk to humans New virus in humans Little/no spread among humans Small clusters, localized Limited spread among humans Increased and sustained spread in general human population Current H5N1 status

29. 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???

30. Pandemic Flu Today 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

31. Are we more or less at risk today compared to 1918?

32. 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

33. 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.

34. 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

35. 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.

36. 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

37. 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

38. What might happen in a severe pandemic?

39. 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

40. 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

41. Who Infects Whom?

42. A Typical Family’s Day Work Lunch Work Carpool Carpool Shopping Home Home Car Car Daycare Bus School Bus time

43. Others Use the Same Locations

44. Time Slice of a Typical Family’s Day

45. Who’s in contact doing what at 10 AM? Work Shopping Daycare School

46. A Scared Family’s Possible Day Home Home

47. 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.

48. 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

49. 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

50. 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