Pandemic Response for Rural EMS

Pandemic Response for Rural EMS

Nick Nudell, MS, NRPNick Nudell, MS, NRP

• Prepared for and presented to EMS providers in Connecticut in 2006.

• Data has not been reevaluated for the 2009 Swine outbreak.

• Prepared for and presented to EMS providers in Connecticut in 2006.

• Data has not been reevaluated for the 2009 Swine outbreak.

PrioriHealth Partners, LLPPrioriHealth Partners, LLP

Pandemics are not a new threat!Pandemics are not a new threat!

Pandemics InfluenzaPandemics Influenza

• Influenza Pandemics are believed to have occurred for at least 300 years at unpredictable intervals.

• Influenza Pandemics are believed to have occurred for at least 300 years at unpredictable intervals.

The 1918 Spanish flu pandemic National Museum of Health and Medicine, Armed Forces Institute of Pathology

20th Century Influenza Pandemics20th Century Influenza Pandemics

• 1918 Spanish Flu A (H1N1) 20-40 mill Deaths 675,000 US Deaths

• 1957 Asian Flu A(H2N2) 1-4 mill Deaths 70,000 US Deaths

• 1968 Hong Kong Flu A(H3N2) 1-4 mill Deaths 34,000 US Deaths

• Swine Flu 1976 emphasized need for pandemic flu planning.

• 1918 Spanish Flu A (H1N1) 20-40 mill Deaths 675,000 US Deaths

• 1957 Asian Flu A(H2N2) 1-4 mill Deaths 70,000 US Deaths

• 1968 Hong Kong Flu A(H3N2) 1-4 mill Deaths 34,000 US Deaths

• Swine Flu 1976 emphasized need for pandemic flu planning.

20th Century Influenza Pandemics (Cont’d)20th Century Influenza Pandemics (Cont’d)

• Avian Flu 1997 (AH5N1) “chicken flu” – 18 cases including 6 deaths, more than 1 million chickens were killed in Hong Kong

• Avian Flu 2003 (AH5N1) 2 persons with confirmed infection, two deaths.

• (H7N7) Over 80 cases of mild disease and 1 death in the Netherlands

• Avian Flu 1997 (AH5N1) “chicken flu” – 18 cases including 6 deaths, more than 1 million chickens were killed in Hong Kong

• Avian Flu 2003 (AH5N1) 2 persons with confirmed infection, two deaths.

• (H7N7) Over 80 cases of mild disease and 1 death in the Netherlands

CT Avian IndustryCT Avian Industry

CT Avian IndustryCT Avian Industry

• 240 Poultry Farms

• 1st in New England for – Density of Egg Laying Poultry– Chickens Sold– Egg Production and value (per sq/mile)

• 2nd in New England Egg Production with 230 eggs per person/year

• 240 Poultry Farms

• 1st in New England for – Density of Egg Laying Poultry– Chickens Sold– Egg Production and value (per sq/mile)

• 2nd in New England Egg Production with 230 eggs per person/year

Pandemic InfluenzaPandemic Influenza

• The nature and severity for the next Pandemic cannot be predicted with any certainty.

• Preparedness Planning is imperative to lessen the impact of a Pandemic

• The nature and severity for the next Pandemic cannot be predicted with any certainty.

• Preparedness Planning is imperative to lessen the impact of a Pandemic

Influenza Pandemic RequirementsFor A Health SystemInfluenza Pandemic RequirementsFor A Health System• Adequate staffing

– EMS Providers– Infectious Disease – Health Care

Epidemiologists– ED Nursing– Respiratory Therapists– X-Ray techs– Infection Control

Professionals – Occupational Health

Professionals– Environmental Services

Personnel– Clinical Microbiology

Technologist

• Adequate staffing– EMS Providers– Infectious Disease – Health Care

Epidemiologists– ED Nursing– Respiratory Therapists– X-Ray techs– Infection Control

Professionals – Occupational Health

Professionals– Environmental Services

Personnel– Clinical Microbiology

Technologist

Influenza Pandemic Requirements For Health System (Cont’d)Influenza Pandemic Requirements For Health System (Cont’d)• Adequate staffing should not be assumed!

– Only 32.5% of Florida’s licensed community healthcare providers are willing and able to respond to a high risk event, such as the Avian Flu

(n=2,279, MD- 34.6%, RN-38.4% , RPh-17.4%)

Reference - Crane, Jeffrey S. Assessment of the Community Healthcare Providers' Ability and Willingness to Respond to a Bioterrorism Attack in Florida. 1 ed. UMI Publishing, Ann Arbor, MI. 2005. Report located at http://www.jscrane.com/index-7.html

• Adequate staffing should not be assumed!

– Only 32.5% of Florida’s licensed community healthcare providers are willing and able to respond to a high risk event, such as the Avian Flu

(n=2,279, MD- 34.6%, RN-38.4% , RPh-17.4%)

Reference - Crane, Jeffrey S. Assessment of the Community Healthcare Providers' Ability and Willingness to Respond to a Bioterrorism Attack in Florida. 1 ed. UMI Publishing, Ann Arbor, MI. 2005. Report located at http://www.jscrane.com/index-7.html

Pandemic Requirements For A Health System (Cont’d)Pandemic Requirements For A Health System (Cont’d)

• Training– Initial– Just-in-time

• Protective equipment– Surgical masks, Disposable long-sleeve gowns

and gloves, eye protection– N-95 or PAPRS

• Training• Fit testing• Battery maintenance• Storage

• Training– Initial– Just-in-time

• Protective equipment– Surgical masks, Disposable long-sleeve gowns

and gloves, eye protection– N-95 or PAPRS

• Training• Fit testing• Battery maintenance• Storage

Pandemic Requirements For A Health System (Cont’d)Pandemic Requirements For A Health System (Cont’d)

• Hand hygiene and cough etiquette– Signage– Soap, alcohol hand rubs, paper towels,

tissue and containers, waste baskets, and surgical masks

– Ambulance contamination and decontamination procedures

• Hand hygiene and cough etiquette– Signage– Soap, alcohol hand rubs, paper towels,

tissue and containers, waste baskets, and surgical masks

– Ambulance contamination and decontamination procedures

Pandemic Requirements For A Health System (Cont’d)Pandemic Requirements For A Health System (Cont’d)

• X-Ray Equipment

• Mechanical ventilation– Transport Ventilators– Respiratory circuits (adult & pediatric)– Oxygen Supply– Scope of Practice– Dedicated facility for disinfecting, cleaning

ventilators

• X-Ray Equipment

• Mechanical ventilation– Transport Ventilators– Respiratory circuits (adult & pediatric)– Oxygen Supply– Scope of Practice– Dedicated facility for disinfecting, cleaning

ventilators

Pandemic Requirements For A Health System (Cont’d)Pandemic Requirements For A Health System (Cont’d)

• Pharmaceuticals and Diagnostic Testing– Oseltamivir and Amantadine– Influenza and Pneumococcal Vaccine– Rapid Viral Antigen Tests– Respiratory Viral Cultures

• Pharmaceuticals and Diagnostic Testing– Oseltamivir and Amantadine– Influenza and Pneumococcal Vaccine– Rapid Viral Antigen Tests– Respiratory Viral Cultures

Pandemic Requirements For A Health System (Cont’d)Pandemic Requirements For A Health System (Cont’d)

• Specific resources & destinations for cohorting patients– Triage– Multi-patient transport– Designated transport units– In-patients Pediatric and Adult

• ICU• Intermediate Care• Wards

• Specific resources & destinations for cohorting patients– Triage– Multi-patient transport– Designated transport units– In-patients Pediatric and Adult

• ICU• Intermediate Care• Wards

Federal Pandemic Influenza PlanFederal Pandemic Influenza Plan

• Pandemic “Influenza Plan” US Department of Health and Human Services released November 2005

• 396 Page Plan with 8 Page Executive Summary

• Pandemic “Influenza Plan” US Department of Health and Human Services released November 2005

• 396 Page Plan with 8 Page Executive Summary

Executive Summary of HHS Pandemic Influenza PlanExecutive Summary of HHS Pandemic Influenza Plan

• Influenza Pandemic has potential to cause more deaths and illness then any other Public Health Threat

• If pandemic occurs with similar virulence of 1918 strain, 1.9 million Americans could die and 10 million could be hospitalized over the pandemic course which may evolve over a year or more.

• Influenza Pandemic has potential to cause more deaths and illness then any other Public Health Threat

• If pandemic occurs with similar virulence of 1918 strain, 1.9 million Americans could die and 10 million could be hospitalized over the pandemic course which may evolve over a year or more.

• Novel Influenza virus could emerge from anywhere in world at any time

• Particular concern is about Avian (H5N1) virus currently circulating in Asia and parts of Europe

• Outbreaks of Influenza H5N1 have occurred among poultry in several countries in Asia Since 1997

• Novel Influenza virus could emerge from anywhere in world at any time

• Particular concern is about Avian (H5N1) virus currently circulating in Asia and parts of Europe

• Outbreaks of Influenza H5N1 have occurred among poultry in several countries in Asia Since 1997

Executive Summary of HHS Pandemic Influenza PlanCont’d

Executive Summary of HHS Pandemic Influenza PlanCont’d

Avian Influenza In HumansAvian Influenza In Humans

• More than 100 confirmed cases of Human Infection with Avian Influenza Viruses have been reported since 1997

• Most of these cases are thought to have resulted from direct contact with infected poultry or contaminated surfaces

• To date human infections with Avian Influenza a viruses detected since 1997 have not resulted in sustained human to human transmission

• More than 100 confirmed cases of Human Infection with Avian Influenza Viruses have been reported since 1997

• Most of these cases are thought to have resulted from direct contact with infected poultry or contaminated surfaces

• To date human infections with Avian Influenza a viruses detected since 1997 have not resulted in sustained human to human transmission

Avian Influenza Viruses Infecting HumansAvian Influenza Viruses Infecting Humans

• Hong Kong 2003 one child infected recovered.

• New York 2003 One patient recovered.

• Canada 2004 Mild eye infection following poultry outbreak.

• Thailand and Vietnam 2004 and other parts of Asia in 2004-2005.

• Hong Kong 2003 one child infected recovered.

• New York 2003 One patient recovered.

• Canada 2004 Mild eye infection following poultry outbreak.

• Thailand and Vietnam 2004 and other parts of Asia in 2004-2005.

• Sustained Human to Human transmission anywhere in the world will be the triggering event to initiate a Pandemic Response by US

• Sustained Human to Human transmission anywhere in the world will be the triggering event to initiate a Pandemic Response by US

Only a matter of… time!Only a matter of… time!

Characteristic Moderate (1958/68-like) Severe (1918-like)

Illness 100 Million (30%) 100 million (30%)

Outpatient Medical Care

50 Million (50%) 50 Million (50%)

Hospitalization 865,000 9,900,000

ICU Care 128,750 1,485,000

Mechanical Ventilation

64,875 742,500

Deaths 209,000 1,903,000

* Estimates based on extrapolation from past pandemics in the United States. Note that these estimates do not include the potential impact of interventions not available during the 20 th century pandemics.

Number of Episodes of Illness, Healthcare Utilization, and Death Associated with Moderate and Severe Pandemic Influenza Scenarios*Number of Episodes of Illness, Healthcare Utilization, and Death Associated with Moderate and Severe Pandemic Influenza Scenarios*

ConnecticutConnecticut• 2004 Population of 3.5 mill (1.2% of US)• 21% of CT population is “rural”

• 2004 Population of 3.5 mill (1.2% of US)• 21% of CT population is “rural”

Characteristic Moderate (1958/68-like) Severe (1918-like)

Illness 1,050,000 (30%) 1,050,000 (30%)

Outpatient Medical Care

525,000 (50%)110,250

525,000 (50%)110,250

Hospitalization10,0902,120

115,50024,255

ICU Care1,500315

17,3253,650

Mechanical Ventilation

750160

8,6601,850

Deaths 2,450515

22,2004,700

• Past Pandemics have spread worldwide within months

• Are expected to spread even more quickly today given modern travel patterns

• Past Pandemics have spread worldwide within months

• Are expected to spread even more quickly today given modern travel patterns

Rural ConnecticutRural Connecticut

CT Influenza Pandemic PlanCT Influenza Pandemic Plan

• Pandemic Period (cases in the U.S.) – Governor will declare a “Public Health

Emergency.” – Governor will work with:

• DPH, • Office of Public Affairs, and • Department of Emergency Management and

Homeland Security (DEMHS)

• Pandemic Period (cases in the U.S.) – Governor will declare a “Public Health

Emergency.” – Governor will work with:

• DPH, • Office of Public Affairs, and • Department of Emergency Management and

Homeland Security (DEMHS)

CT Influenza Pandemic PlanCT Influenza Pandemic Plan• DPH Emergency Command Center (ECC) and DPH ICS activated.

• State Epidemiologist will manage the epidemiologic and immunization in collaboration with local health departments, hospitals and other key response partners.

• DPH will provide assistance to the pandemic response as needed:– Epidemiology Program, – Immunizations Program, – Environmental Health Section, – Health Care Systems Regulation Branch, – Laboratory Branch, – Local Health Administration Branch, – Regulatory Services Branch, – Office of Communications, – Office of Emergency Medical Services, and – Office of Public Health Preparedness (OPHP).

• DPH Emergency Command Center (ECC) and DPH ICS activated.

• State Epidemiologist will manage the epidemiologic and immunization in collaboration with local health departments, hospitals and other key response partners.

• DPH will provide assistance to the pandemic response as needed:– Epidemiology Program, – Immunizations Program, – Environmental Health Section, – Health Care Systems Regulation Branch, – Laboratory Branch, – Local Health Administration Branch, – Regulatory Services Branch, – Office of Communications, – Office of Emergency Medical Services, and – Office of Public Health Preparedness (OPHP).

CT Influenza Pandemic PlanCT Influenza Pandemic Plan

• Each hospital and medical care provider should develop or update its own pandemic response plan to be consistent with the National and CT Pandemic Influenza Response Plans

• Each hospital and medical care provider should participate in development of a regional pandemic influenza response plan

• Each hospital and medical care provider should develop or update its own pandemic response plan to be consistent with the National and CT Pandemic Influenza Response Plans

• Each hospital and medical care provider should participate in development of a regional pandemic influenza response plan

CT Influenza Pandemic PlanCT Influenza Pandemic Plan

• Each hospital and major medical care provider will establish its own EOC and be prepared to participate collaboratively with DPH as needed to:– collect information to monitor the pandemic, – provide information and respond to patient inquiry, – isolate patients and enforce quarantine of employees and

patients as needed, – vaccinate employees and patients and/or – provide antiviral agents to health care providers and patients in

accordance with DPH recommendations, and – conduct and enforce other activities as may be declared

necessary by the Governor and Commissioner of Public Health.

• Each hospital and major medical care provider will establish its own EOC and be prepared to participate collaboratively with DPH as needed to:– collect information to monitor the pandemic, – provide information and respond to patient inquiry, – isolate patients and enforce quarantine of employees and

patients as needed, – vaccinate employees and patients and/or – provide antiviral agents to health care providers and patients in

accordance with DPH recommendations, and – conduct and enforce other activities as may be declared

necessary by the Governor and Commissioner of Public Health.

CT Influenza Pandemic PlanCT Influenza Pandemic Plan• Licensed health care workers (DPH 5/03)

– Physicians 10,805 – Registered Nurses 40,080 – Licensed Practical Nurses 9,640 – Paramedics 1,380 – Emergency Medical Technicians 8,980

• Essential service providers (DPH 1/06) – Medical Response Technician (MRT) 5,871 – Emergency Medical Technician (EMT) 9,686 – EMT – Intermediate 843 – Paramedic 1,586 – Firefighters (est. from CT Fire Academy) 21,000 – Local Law Enforcement 7,522 – State Law Enforcement 1,200 – Air National Guard (as of 01/23/06) 1,020 – Army National Guard (as of 01/23/06) 3,212 – State Public Health workforce (as of 5/05) 848 – Local Public Health workforce (as of 2004) 1,802

• Correctional population 19,216

• Licensed health care workers (DPH 5/03) – Physicians 10,805 – Registered Nurses 40,080 – Licensed Practical Nurses 9,640 – Paramedics 1,380 – Emergency Medical Technicians 8,980

• Essential service providers (DPH 1/06) – Medical Response Technician (MRT) 5,871 – Emergency Medical Technician (EMT) 9,686 – EMT – Intermediate 843 – Paramedic 1,586 – Firefighters (est. from CT Fire Academy) 21,000 – Local Law Enforcement 7,522 – State Law Enforcement 1,200 – Air National Guard (as of 01/23/06) 1,020 – Army National Guard (as of 01/23/06) 3,212 – State Public Health workforce (as of 5/05) 848 – Local Public Health workforce (as of 2004) 1,802

• Correctional population 19,216

Need to be actively involved!Need to be actively involved!

• Feb 2006 GAO report identifies lack of transport resources for nursing home evacuations

• Planners under/over estimate EMS transport capabilities

• PAPRS and decon training/equipment are expensive

• Feb 2006 GAO report identifies lack of transport resources for nursing home evacuations

• Planners under/over estimate EMS transport capabilities

• PAPRS and decon training/equipment are expensive

Thank you!Thank you!

Information Systems, Security, & Technology Management – Clinical, Operations, & Quality

Management – Contract Oversight – Provider & Patient Safety

PrioriHealth Partners, LLP Voice (760) 405-6869

http://www.priorihealth.com/nick@priorihealth.com