Download - Ethical, Legal and Social Implications of First Response in Disasters Rome, 11-12 December 2008
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Ethical, Legal and Social Implications of First Response in Disasters
Rome, 11-12 December 2008
Ethical, Legal and Social Implications of First Response in Disasters
Rome, 11-12 December 2008
Toby L Merlin, MDDeputy Director, Influenza Coordination Unit
US Centers for Disease Control and Prevention
Toby L Merlin, MDDeputy Director, Influenza Coordination Unit
US Centers for Disease Control and Prevention
Pandemic Influenza: Special Considerations for First Responders
Pandemic Influenza: Special Considerations for First Responders
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1996-2001 1996-2004 1996-20081996-2005
Expansion of clade 2 into five 2nd order clades
Expansion of 2nd order clades into additional 3rd order clades
0
5
3
9
0.002 0.005
0
3
4
7
5
6
8
1
2
9
0.005 0.005
0
3
4
7
5
6
9
8
1
2.4
2.1
2.5
2.2
2.3
0
3
7
4
5
69
8
12.4
2.1.1
2.1.22.1.3
2.5
2.2
2.3.1
2.3.22.3.32.3.4
Evolution of the H5 hemagglutinin (Clade 2): 1996-2008
T. Davis-MVVB
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Emergence of Influenza A Viruses in HumansEmergence of Influenza A Viruses in Humans
H1H1
H1H1H3H3
H2H2
H7*H7*
H5*H5*
H9*H9*
19181918SpanishFlu H1N1SpanishFlu H1N1
19571957Asian
Flu H2N2Asian
Flu H2N2
1968 1968Hong KongFlu H3N2
Hong KongFlu H3N2
1980 1996 20021980 1996 2002
1997 2003-2008 1997 2003-2008
1915 1925 1935 1945 1955 1965 1975 1985 1995 20081915 1925 1935 1945 1955 1965 1975 1985 1995 2008
* Avian Flu* Avian Flu
2003 2004
2003 2004
1998 1999
2003
1998 1999
2003
19771977
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Impact of Next PandemicImpact of Next Pandemic
If an influenza pandemic like If an influenza pandemic like 1918-20 occurred today:1918-20 occurred today:
If an influenza pandemic like If an influenza pandemic like 1918-20 occurred today:1918-20 occurred today:
• 62 million people would 62 million people would die worldwide die worldwide
• 96% of deaths in 96% of deaths in developing worlddeveloping world
• Highest deaths among Highest deaths among 15-29 year olds15-29 year olds
• 62 million people would 62 million people would die worldwide die worldwide
• 96% of deaths in 96% of deaths in developing worlddeveloping world
• Highest deaths among Highest deaths among 15-29 year olds15-29 year olds
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Goals of Pandemic MitigationGoals of Pandemic Mitigation
Days since First Case
Dai
ly C
ases
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Pandemic InfluenzaSpecial Considerations for First Responders
in US Government Planning:
Pandemic InfluenzaSpecial Considerations for First Responders
in US Government Planning:
• Ethical principlesEthical principles• Occupational riskOccupational risk• Antiviral medicationAntiviral medication• Pandemic vaccinePandemic vaccine• Planning and coordination (Emergency Planning and coordination (Emergency
Medical Services checklist) Medical Services checklist)
• Ethical principlesEthical principles• Occupational riskOccupational risk• Antiviral medicationAntiviral medication• Pandemic vaccinePandemic vaccine• Planning and coordination (Emergency Planning and coordination (Emergency
Medical Services checklist) Medical Services checklist)
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Ethical Principles Ethical Principles
• Minimizing the harms of an influenza pandemic Minimizing the harms of an influenza pandemic may require targeting resources to specific may require targeting resources to specific groups that protect health and safety and groups that protect health and safety and provide essential community services. provide essential community services.
• Targeting limited resources to protect societal Targeting limited resources to protect societal interests is ethically appropriate.interests is ethically appropriate.
• Minimizing the harms of an influenza pandemic Minimizing the harms of an influenza pandemic may require targeting resources to specific may require targeting resources to specific groups that protect health and safety and groups that protect health and safety and provide essential community services. provide essential community services.
• Targeting limited resources to protect societal Targeting limited resources to protect societal interests is ethically appropriate.interests is ethically appropriate.
Principal of Preserving Function of SocietyPrincipal of Preserving Function of SocietyPrincipal of Preserving Function of SocietyPrincipal of Preserving Function of Society
Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. February, 2007Control and Prevention. February, 2007
Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. February, 2007Control and Prevention. February, 2007
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Ethical Principles Ethical Principles
• Workers who assume increased risks due to their Workers who assume increased risks due to their occupation and who provide benefits broadly to occupation and who provide benefits broadly to society – such as healthcare workers, firefighters, society – such as healthcare workers, firefighters, emergency medical services personnel, etc. – emergency medical services personnel, etc. – should be protected, if possible.should be protected, if possible. • Society has an obligation to provide health Society has an obligation to provide health workers with the protection and tools they need. workers with the protection and tools they need.
• Workers who assume increased risks due to their Workers who assume increased risks due to their occupation and who provide benefits broadly to occupation and who provide benefits broadly to society – such as healthcare workers, firefighters, society – such as healthcare workers, firefighters, emergency medical services personnel, etc. – emergency medical services personnel, etc. – should be protected, if possible.should be protected, if possible. • Society has an obligation to provide health Society has an obligation to provide health workers with the protection and tools they need. workers with the protection and tools they need.
Principle of ReciprocityPrinciple of ReciprocityPrinciple of ReciprocityPrinciple of Reciprocity
Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. February, 2007Control and Prevention. February, 2007
Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. February, 2007Control and Prevention. February, 2007
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Ethical Principles Ethical Principles
• Confronting some degree of personal risk Confronting some degree of personal risk comes with the job of being a health comes with the job of being a health professional or first responder. They have an professional or first responder. They have an ethical contract with society at large. ethical contract with society at large.
• Confronting some degree of personal risk Confronting some degree of personal risk comes with the job of being a health comes with the job of being a health professional or first responder. They have an professional or first responder. They have an ethical contract with society at large. ethical contract with society at large.
Professional ResponsibilityProfessional ResponsibilityProfessional ResponsibilityProfessional Responsibility
Reference: White paper prepared for the Centers for Disease Control and Reference: White paper prepared for the Centers for Disease Control and Prevention. Ethics Subcommittee of the Advisory Committee to the Director. Prevention. Ethics Subcommittee of the Advisory Committee to the Director.
Reference: White paper prepared for the Centers for Disease Control and Reference: White paper prepared for the Centers for Disease Control and Prevention. Ethics Subcommittee of the Advisory Committee to the Director. Prevention. Ethics Subcommittee of the Advisory Committee to the Director.
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Occupational Risk Pyramid for Pandemic Influenza
Occupational Risk Pyramid for Pandemic Influenza
VeryHigh
High
Medium
Lower Risk (Caution)
Reference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health Administration
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Occupational Risk Pyramid for Pandemic Influenza
Occupational Risk Pyramid for Pandemic Influenza
• Performing aerosol-generating Performing aerosol-generating proceduresprocedures
• Performing aerosol-generating Performing aerosol-generating proceduresproceduresVery
High
High
• Entering rooms of suspect patientsEntering rooms of suspect patients
• Transporting suspect patients in Transporting suspect patients in closed vehicleclosed vehicle
• Performing autopsies on suspect Performing autopsies on suspect patientspatients
• Entering rooms of suspect patientsEntering rooms of suspect patients
• Transporting suspect patients in Transporting suspect patients in closed vehicleclosed vehicle
• Performing autopsies on suspect Performing autopsies on suspect patientspatients
Reference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health AdministrationReference: US Occupational Safety and Health Administration
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Personal Protective EquipmentPersonal Protective Equipment
• N95 (or higher) respirators during N95 (or higher) respirators during direct contact with pandemic direct contact with pandemic influenza patientsinfluenza patients
• Surgical masks if N95 respirators Surgical masks if N95 respirators not availablenot available
• Use of surgical masks for “source Use of surgical masks for “source control” of symptomatic personscontrol” of symptomatic persons
• Gloves, eye protection, gowns Gloves, eye protection, gowns
• N95 (or higher) respirators during N95 (or higher) respirators during direct contact with pandemic direct contact with pandemic influenza patientsinfluenza patients
• Surgical masks if N95 respirators Surgical masks if N95 respirators not availablenot available
• Use of surgical masks for “source Use of surgical masks for “source control” of symptomatic personscontrol” of symptomatic persons
• Gloves, eye protection, gowns Gloves, eye protection, gowns
Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Health Care Setting during and Influenza Pandemic. October 2006. www.pandemicflu.gov Guidance on Preparing Workplaces for an Influenza Pandemic. OSHA 2007. www.pandemicflu.gov
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Antiviral MedicationAntiviral Medication
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Antiviral MedicationAntiviral Medication
Pre-exposure Prophylaxis
Post-exposure Prophylaxis
Rx
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Antiviral Medication:Proposed US Government Guidance
Antiviral Medication:Proposed US Government Guidance
Employers that provide frontline healthcare and Employers that provide frontline healthcare and emergency services should protect employees emergency services should protect employees who will be exposed to ill persons during a who will be exposed to ill persons during a pandemic. This guidance recommends pandemic. This guidance recommends providing providing antiviral prophylaxis to those very antiviral prophylaxis to those very high exposure risk and high exposure risk high exposure risk and high exposure risk employees for the duration of community employees for the duration of community pandemic outbreakspandemic outbreaks..
Employers that provide frontline healthcare and Employers that provide frontline healthcare and emergency services should protect employees emergency services should protect employees who will be exposed to ill persons during a who will be exposed to ill persons during a pandemic. This guidance recommends pandemic. This guidance recommends providing providing antiviral prophylaxis to those very antiviral prophylaxis to those very high exposure risk and high exposure risk high exposure risk and high exposure risk employees for the duration of community employees for the duration of community pandemic outbreakspandemic outbreaks..
Reference: “Considerations for Antiviral Drug Stockpiling by Employers in Reference: “Considerations for Antiviral Drug Stockpiling by Employers in Preparation for an Influenza Pandemic” HHS, scheduled publication Dec 16, 2008 Preparation for an Influenza Pandemic” HHS, scheduled publication Dec 16, 2008 www.pandemicflu.govwww.pandemicflu.gov
Reference: “Considerations for Antiviral Drug Stockpiling by Employers in Reference: “Considerations for Antiviral Drug Stockpiling by Employers in Preparation for an Influenza Pandemic” HHS, scheduled publication Dec 16, 2008 Preparation for an Influenza Pandemic” HHS, scheduled publication Dec 16, 2008 www.pandemicflu.govwww.pandemicflu.gov
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Pandemic Influenza VaccinePandemic Influenza VaccineAllocation for US PopulationAllocation for US Population
Pandemic Influenza VaccinePandemic Influenza VaccineAllocation for US PopulationAllocation for US Population
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Pandemic Influenza Vaccination TiersPandemic Influenza Vaccination Tiers
Guidance on Allocating and Targeting Pandemic influenza Vaccine, HHS, DHS 2008. Guidance on Allocating and Targeting Pandemic influenza Vaccine, HHS, DHS 2008. www.pandemicflu.gov www.pandemicflu.gov
Guidance on Allocating and Targeting Pandemic influenza Vaccine, HHS, DHS 2008. Guidance on Allocating and Targeting Pandemic influenza Vaccine, HHS, DHS 2008. www.pandemicflu.gov www.pandemicflu.gov
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Emergency Medical Service ChecklistEmergency Medical Service Checklist
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Toby L Merlin, MDDeputy Director, Influenza Coordination Unit
US Centers for Disease Control and Prevention
Toby L Merlin, MDDeputy Director, Influenza Coordination Unit
US Centers for Disease Control and Prevention
001 404 639 [email protected] 404 639 [email protected]
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References www.pandemicflu.gov
References www.pandemicflu.gov
• Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention, February 2007 (www.cdc.gov)
• Guidance on Antiviral Drug Use during an Influenza Pandemic, December 2008
• Considerations for Antiviral Drug Stockpiling by Employers, December 2008
• Guidance on Allocating and Targeting Pandemic Influenza Vaccine• Interim Guidance on Planning for the Use of Surgical Masks and
Respirators in Health Care Settings during an Influenza Pandemic, October 2006
• Emergency Medical Service and Non-Emergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist
• Citizen Voices on Pandemic Flu Choices: A Report of the Public Engagement Pilot Project on Pandemic Influenza
• Guidance for Preparing Workplaces for a Pandemic (http://www.osha.gov/Publications/OSHA3327pandemic.pdf)
• Ethical Guidelines in Pandemic Influenza - Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention, February 2007 (www.cdc.gov)
• Guidance on Antiviral Drug Use during an Influenza Pandemic, December 2008
• Considerations for Antiviral Drug Stockpiling by Employers, December 2008
• Guidance on Allocating and Targeting Pandemic Influenza Vaccine• Interim Guidance on Planning for the Use of Surgical Masks and
Respirators in Health Care Settings during an Influenza Pandemic, October 2006
• Emergency Medical Service and Non-Emergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist
• Citizen Voices on Pandemic Flu Choices: A Report of the Public Engagement Pilot Project on Pandemic Influenza
• Guidance for Preparing Workplaces for a Pandemic (http://www.osha.gov/Publications/OSHA3327pandemic.pdf)