pandemic influenza: table-top exercise october 13, 2009

Pandemic Influenza:Pandemic Influenza:Table-Top ExerciseTable-Top Exercise

October 13, 2009October 13, 2009

THE STORM IS BREWING…THE STORM IS BREWING…

Health Alert NetworkHealth Alert NetworkAdvisory #1Advisory #1

Health Alert NetworkHealth Alert NetworkAdvisory #1Advisory #1

An outbreak of severe respiratory illness is identified in a small village in southern China. 25 cases have been reported among all age groups, all patients have had direct contact with poultry.

Viral cultures are positive for type-A influenza virus.

The isolates have been sent to CDC for further characterization.

Discussion Questions:Discussion Questions: HAN # 1HAN # 1

Please refer to question list:

1) developing a plan and monitoring

HAN #2HAN #2

HAN #2HAN #2

Viral cultures from the patients in China tested positive for type-A influenza.

The CDC has determined that the isolates are type A H7N3, a subtype that has never before been isolated from humans.

Additional cases of H7N3 are now being reported in southern China in patients who have not had any direct contact with poultry

The affected villages have been quarantined by the Chinese government.

HAN #2HAN #2

The CDC has dispatched a team of epidemiologists to evaluate the outbreak.

All clinicians and state departments of health are alerted for patients with severe respiratory illness and a history of travel to the region of Asia.

Isolates of the H7N3 virus are sent to the U.S. Food and Drug Administration (FDA), so that work can begin to produce a reference strain for vaccine production.

Influenza vaccine manufacturers estimate initial production will take 4 to 6 months.

HAN # 2HAN # 2

The outbreak begins to make The outbreak begins to make headlines in every major newspaper headlines in every major newspaper and becomes the lead story on and becomes the lead story on network news. network news.

U.S. government officials are briefed U.S. government officials are briefed on a daily basis as surveillance is on a daily basis as surveillance is intensified throughout Southeast intensified throughout Southeast Asia.Asia.

Discussion Questions:Discussion Questions:HAN # 2HAN # 2

Please refer to question 2:

Communications

HAN #3HAN #3

HAN #3HAN #3

Cases of H7N3 are reported in Hong Kong, Singapore, South Korea, and Japan. Transmission from human to human has been documented.

Cases are reported in all age groups, young adults appear to be the most severely affected.

Case-fatality rates are approaching 5%.

HAN #3HAN #3

Large numbers of patients are reporting to hospitals, inundating their emergency departments.

Vaccine is not yet available. Supplies

of antiviral drugs are severely limited.

The CDC expects cases to begin appearing in the United States.

Discussion Questions:Discussion Questions:HAN # 3HAN # 3

Please refer to question #3

Student and personnel health

HAN #4HAN #4

HANHANAlert #4Alert #4

Human cases of the H7N3 virus have been Human cases of the H7N3 virus have been identified in the United States. identified in the United States.

Los Angeles reports that large numbers of Los Angeles reports that large numbers of patients have been reporting to their emergency patients have been reporting to their emergency rooms, taxing all local emergency departments.rooms, taxing all local emergency departments.

No cases have been reported in New Mexico, but No cases have been reported in New Mexico, but are expected in the next 1 to 2 weeks.are expected in the next 1 to 2 weeks.

State and local agencies are asked to intensify State and local agencies are asked to intensify influenza surveillance.influenza surveillance.

Discussion Questions: Discussion Questions: HAN #4HAN #4

Please refer to questions 4 and 5

TriageSecurity and Aid

THE STORM HITSTHE STORM HITS

Week OneWeek One Scenario updateScenario update: :

In New Mexico, the In New Mexico, the impact has begun to impact has begun to be felt in earnest. be felt in earnest.

There is a noticeable There is a noticeable increase in the increase in the number of persons number of persons presenting to presenting to emergency rooms emergency rooms with symptoms with symptoms consistent with consistent with influenza. influenza.

Phones at physician Phones at physician offices and the health offices and the health department begin to department begin to ring constantly. ring constantly.

More people—the More people—the “worried well”—are “worried well”—are seeking medical care seeking medical care than actually need it, than actually need it, due to fear about the due to fear about the new strain of virus.new strain of virus.

Week OneWeek One

UNMHUNMHWeeklyWeekly

ncidencencidenceHospitalHospital

CensusCensusTotalTotal

Hospital Admissions 79 321 400

Intensive Care Unit Intensive Care Unit AdmissionsAdmissions 1212 3535 4747

Patients Requiring Patients Requiring VentilatorsVentilators 66 2828 3434

DeathsDeaths 00 1010 1010

Week OneWeek One City schools are beginning to experience both City schools are beginning to experience both

students and staff out sick. About 10 to 15 students and staff out sick. About 10 to 15 percent of their populations are affected.percent of their populations are affected.

AFD and APD enact their existing emergency AFD and APD enact their existing emergency plans to assist with staffing shortages in critical plans to assist with staffing shortages in critical areas.areas.

A CDC/NIH research team has arrived at UNMH A CDC/NIH research team has arrived at UNMH and is requesting access to influenza patients, and is requesting access to influenza patients, their records, and laboratory specimens. their records, and laboratory specimens.

Week TwoWeek Two

Nationwide, accounts of illness are reported by the media.

The is a high demand influenza vaccine, but it is not available.

Elected officials receive angry phone call from constituents demanding antiviral medication and vaccine.

People are demanding answers about why existing antiviral medication is reserved for certain individuals.

Week TwoWeek Two


IncidenceIncidenceHospitalHospital


Hospital AdmissionsHospital Admissions 132132 315315 447447




Week TwoWeek Two Traffic in both directions of Traffic in both directions of

Lomas Blvd approaching Lomas Blvd approaching UNMH has increased, UNMH has increased, causing gridlock at hospital causing gridlock at hospital entrances. entrances.

Large numbers of patients Large numbers of patients are concentrating in the are concentrating in the hallways and waiting hallways and waiting rooms to be seen. Wait rooms to be seen. Wait times are over 8 hours. times are over 8 hours.

The UNM campus is The UNM campus is experiencing about 20% experiencing about 20% absenteeism of students.absenteeism of students.

20% of classes have been 20% of classes have been cancelled due to professor cancelled due to professor absences.absences.

Facilities management and Facilities management and maintenance at both the maintenance at both the hospital and the main hospital and the main campus are experiencing campus are experiencing the same absenteeism the same absenteeism rate.rate.

Week Two Week Two The hospitals’ four day The hospitals’ four day

reserve of disposable reserve of disposable durable goods is durable goods is consumed in 2 days. consumed in 2 days.

At UNMH, the supply At UNMH, the supply of of • critical equipment critical equipment

VentilatorsVentilators monitors monitors etc. etc.

• disposable supplies disposable supplies MasksMasks gowns gowns GlovesGloves etc. etc.

……may not make it may not make it through the week. through the week.

Week TwoWeek Two The City Police Department The City Police Department

and Albuquerque and Albuquerque Ambulance response times Ambulance response times have doubled due to have doubled due to staffing shortages, and the staffing shortages, and the Fire Department response Fire Department response has been systematically has been systematically reduced, consistent with reduced, consistent with their “Flu Protocols”.their “Flu Protocols”.

The Secretary of the New The Secretary of the New Mexico Department of Mexico Department of Health (NMDOH) has Health (NMDOH) has requested, and the requested, and the Governor has declared a Governor has declared a Public Health Emergency.Public Health Emergency.

The Secretary of NMDOH is The Secretary of NMDOH is

beginning to operate under beginning to operate under the Public Health the Public Health Emergency Response Act Emergency Response Act (PHERA).(PHERA).

Discussion Questions:Discussion Questions: Week TwoWeek Two


Prevention of spread of disease

Week ThreeWeek Three Scenario updateScenario update: :

Some local pharmacies Some local pharmacies have run out of antiviral have run out of antiviral medications medications

Pharmacists are unsure Pharmacists are unsure whether they will receive whether they will receive more.more.

Although the health Although the health department has issued department has issued guidelines to physicians on guidelines to physicians on antiviral medication use antiviral medication use and has emphasized the and has emphasized the importance of prioritizing importance of prioritizing persons with underlying persons with underlying illnesses who have recent illnesses who have recent onset of influenza onset of influenza symptoms… symptoms…

……anecdotal information anecdotal information suggests that physicians suggests that physicians have been prescribing have been prescribing antiviral medications more antiviral medications more broadly. broadly.

Week ThreeWeek Three





Intensive Care Unit AdmissionsIntensive Care Unit Admissions 3939 4545 8484

Patients Requiring VentilatorsPatients Requiring Ventilators 1919 3838 5757



The Mayor of the City of Albuquerque The Mayor of the City of Albuquerque has received a small supply of anti-has received a small supply of anti-viral medication from the CDC (500 viral medication from the CDC (500 10-day courses). 10-day courses).

Public concern over the prioritization Public concern over the prioritization of antiviral medications to the police of antiviral medications to the police and fire departments is increasing.and fire departments is increasing.

Week ThreeWeek Three UNMH is experiencing a 20% staff UNMH is experiencing a 20% staff

absentee rate. absentee rate.

Staff that is available is having difficulties Staff that is available is having difficulties getting to work due to traffic, averaging getting to work due to traffic, averaging about 90 additional minutes each way. about 90 additional minutes each way.

The ED census has been increased by The ED census has been increased by 100%, and there are consistently 20 100%, and there are consistently 20 admitted patients in the ER waiting for admitted patients in the ER waiting for floor beds.floor beds.

Week Three

Patients are getting frustrated with the Patients are getting frustrated with the huge lines, and 25% are leaving without huge lines, and 25% are leaving without being seen.being seen.

Some equipment is resupplied. Some equipment is resupplied.

There is conflict with other area hospitals There is conflict with other area hospitals about the receipt of “guaranteed” vendor about the receipt of “guaranteed” vendor managed inventory. managed inventory.

Week ThreeWeek Three UNM:

Main campus also has a 20% absentee rate of staff, and 1/3 of the students have left.

There has been a documented cluster of influenza cases in the Laguna / De Vargas dormitories.


ABQ 911 calls are delayed, and some fire ABQ 911 calls are delayed, and some fire and police calls are not being answered. and police calls are not being answered.

Some local pharmacies have run out of Some local pharmacies have run out of antivirals, others are extremely low. antivirals, others are extremely low.

There was a news report of a pharmacist There was a news report of a pharmacist being beaten up by a crowd demanding being beaten up by a crowd demanding antiviral medication.antiviral medication.

Discussion Questions:Discussion Questions:Week ThreeWeek Three


Expanding capacity

Week FourWeek Four

Albuquerque is overwhelmed by the Albuquerque is overwhelmed by the number of influenza cases.number of influenza cases.

The Office of the Medical Investigator The Office of the Medical Investigator (OMI) has run out of space for bodies, (OMI) has run out of space for bodies, and is requesting refrigerated trucks and is requesting refrigerated trucks for storage. for storage.

Week Four

Rough surveillance estimates Rough surveillance estimates indicate that 30% of the population is indicate that 30% of the population is ill with H7N3 influenza.ill with H7N3 influenza.

There are students sick with There are students sick with influenza stranded in dormitory influenza stranded in dormitory rooms with little food.rooms with little food.

Week FourWeek Four








Week FourWeek Four The UNMH ED is packed; there are The UNMH ED is packed; there are

constantly 30 admitted patients boarding, constantly 30 admitted patients boarding, waiting for beds.waiting for beds.

40% staff attrition40% staff attrition• Some sick, others caring for ill family Some sick, others caring for ill family

membersmembers

Trash is being picked up every other day. Trash is being picked up every other day.

Week Four

Central supply reports that medical Central supply reports that medical equipment reserves are only 15% of equipment reserves are only 15% of normal. Only three days of normal. Only three days of expendable supplies remaining. expendable supplies remaining.

Previous re-supply orders have been Previous re-supply orders have been delayed an additional week, and delayed an additional week, and have only been 40% complete when have only been 40% complete when received.received.

Week FourWeek Four

Main campus reports Main campus reports that 4,000 students that 4,000 students are sick with the flu; are sick with the flu; 75% of classes have 75% of classes have been cancelled due to been cancelled due to illness or illness or absenteeism.absenteeism.

Several academic Several academic

departments have departments have closed due to illness.closed due to illness.

While UNM played While UNM played host to a Collegiate host to a Collegiate Invitational Basketball Invitational Basketball Tournament, several Tournament, several players from Maryland players from Maryland developed the flu, one developed the flu, one required a ventilator.required a ventilator.

Week FourWeek Four The public safety response has worsened, and the The public safety response has worsened, and the

Chief of Police appeared on a local media station Chief of Police appeared on a local media station to encourage neighborhood watch activity.to encourage neighborhood watch activity.

Hospital infection control has noted an increased Hospital infection control has noted an increased rate of decubitus ulcers and nosocomial in rate of decubitus ulcers and nosocomial in hospitalized patients.hospitalized patients.

A medication error led to the death of a patient A medication error led to the death of a patient on 7 – South.on 7 – South.

An increase in medication errors is noted.An increase in medication errors is noted.

Discussion Questions:Discussion Questions:Week FourWeek Four


Shortages

Week FiveWeek Five

Recall that these numbers are for UNM, and are a fraction of the Albuquerque and New Mexico impact.








Week FiveWeek Five

The NM DOH has received a fragment of the SNS. The NM DOH has received a fragment of the SNS. They called the hospital EOC to arrange delivery. They called the hospital EOC to arrange delivery.

The media has reported that both a student from The media has reported that both a student from and an ICU nurse from UNMH died from the flu.and an ICU nurse from UNMH died from the flu.

There is an outbreak of influenza at the CYFD There is an outbreak of influenza at the CYFD facility on Edith Blvd. 75 children are ill, two facility on Edith Blvd. 75 children are ill, two require mechanical ventilation. require mechanical ventilation.

Week Five: Discussion Questions

Please refer to questions 10 and 11

Other areas of needThe strategic national stockpile

Week SixWeek Six Grocery stores are Grocery stores are

suffering shortages of suffering shortages of food supplies resulting food supplies resulting from ill truckers who from ill truckers who usually deliver those usually deliver those supplies. supplies.

Gasoline prices Gasoline prices average $5.90/gallon. average $5.90/gallon. Many stations in Many stations in Albuquerque have no Albuquerque have no gas. gas.

Some looting has been Some looting has been reportedreported

Week SixWeek Six








Week SixWeek Six Many area residents are

afraid to venture out for fear of catching the flu.

The police department has reported numerous deaths of solitary, elderly people.

Hundreds are staying home, and their essential supplies—such as food—are becoming depleted.

Week Six: Discussion QuestionsWeek Six: Discussion Questions

Please refer to question # 12

Week SevenWeek Seven

Hospital staff are exhausted. Hospital staff are exhausted.

All those available to provide health care All those available to provide health care have been brought in. There are no have been brought in. There are no remaining staffing pools.remaining staffing pools.

The pharmaceutical companies developing The pharmaceutical companies developing the influenza vaccine are ahead of the influenza vaccine are ahead of schedule. They expect the first New schedule. They expect the first New Mexico shipment to be delivered in 12 Mexico shipment to be delivered in 12 weeks. weeks.

Week SevenWeek Seven


ncidencencidenceHospitalHospital






Discussion Questions: Discussion Questions: Week SevenWeek Seven

Please refer to question #12Please refer to question #12

Mortuary issuesMortuary issues

Week EightWeek Eight The hospital The hospital

epidemiologist reports epidemiologist reports that the number of flu that the number of flu patients has declined patients has declined for 3 consecutive for 3 consecutive weeks. weeks.

Anti-viral medication Anti-viral medication is now becoming is now becoming available in quantities available in quantities sufficient for public sufficient for public use. use.

Week EightWeek Eight








Week NineWeek Nine

For the first time in For the first time in several weeks, several weeks, there were no new there were no new cases of influenza cases of influenza reported.reported.

Students are Students are demanding tuition demanding tuition refunds for classes refunds for classes cancelled during cancelled during the semester.the semester.

Week NineWeek Nine








Week TenWeek Ten

Another week of no Another week of no new influenza new influenza cases.cases.

Week TenWeek Ten








Discussion Questions:Discussion Questions:Weeks Nine and TenWeeks Nine and Ten

Please refer to question # 13 After the worst is over

Thank YouThank You

pandemic influenza: table-top exercise october 13, 2009

Documents

monitoring slide

communications slide

personnel health slide

human cases

han alert

additional cases of

h7n3 virus

large numbers of patients