Pandemic PlanningPandemic Planning

Gerard Doyle, MD MPHGerard Doyle, MD MPH

UWSMPHUWSMPH

3 October, 20083 October, 2008

Topics for the Day:Topics for the Day:

What are the potential threats?What are the potential threats? Where are we?Where are we? Where do we need to be?Where do we need to be? How do we get there?How do we get there?

Why Should I Care?Why Should I Care?

It Could HappenIt Could Happen• ““Even Paranoids Have Enemies”Even Paranoids Have Enemies”• It It hashas happened: 1918, SARS, etc? happened: 1918, SARS, etc?

It Could Happen to YouIt Could Happen to You• What’s out there?What’s out there?• Sanctions and other penalties?Sanctions and other penalties?

JCAHO, ACEP, etc. JCAHO, ACEP, etc.

What Is A Pandemic?What Is A Pandemic?

Pandemic occurs when: Pandemic occurs when: • NewNew organism appears organism appears

Reassorted influenza genes, for exampleReassorted influenza genes, for example

• Human population has poor immunity Human population has poor immunity • Result is simultaneous epidemicsResult is simultaneous epidemics• Enormous death and illness worldwide Enormous death and illness worldwide

From WHO

Not so long ago….Not so long ago….

Are We Overdue?Are We Overdue?

Pandemic fluPandemic flu• 10-13 since 170010-13 since 1700

SWAG: 3% annualSWAG: 3% annual Effect of H5N1?Effect of H5N1?

WHO Pandemic Flu PhasesWHO Pandemic Flu Phases

Interpandemic PeriodInterpandemic Period• Phase 1Phase 1::

No new human virusNo new human virus

• Phase 2Phase 2: : No new human virusNo new human virus

• Animal virusAnimal virus Substantial riskSubstantial risk

Pandemic alert periodPandemic alert period• Phase 3Phase 3: New subtype : New subtype

No human-to-human No human-to-human

• Phase 4Phase 4: Small clusters : Small clusters Limited spread Limited spread

• Virus not adapted Virus not adapted

• Phase 5Phase 5: Larger clusters: Larger clusters Virus better adapted Virus better adapted

• Substantial risk Substantial risk

Pandemic periodPandemic period• Phase 6Phase 6: Pandemic: Pandemic

Sustained transmissionSustained transmission

How How BadBad is the Big Bad Wolf? is the Big Bad Wolf?

Mortality rates of prior flu pandemicsMortality rates of prior flu pandemics• 1918: 2.5% case fatality rate1918: 2.5% case fatality rate

1957 and 1968 were not as bad as 19181957 and 1968 were not as bad as 1918 Are we different today?Are we different today?

• Populations density much higherPopulations density much higher• Travel much easier and fasterTravel much easier and faster• More people are chronically illMore people are chronically ill

Are current plans’ predictions valid?Are current plans’ predictions valid?• What can we learn from the past?What can we learn from the past?

National Pandemic Flu PlanNational Pandemic Flu Plan

HHS convened panel in 2005HHS convened panel in 2005• State and local health officialsState and local health officials

Funding and some guidance, but….Funding and some guidance, but….• YOYO for up to a month?YOYO for up to a month?• Local/private agencies bear the burdenLocal/private agencies bear the burden

Disaster Cycle:Disaster Cycle:

PreparednessPreparedness• Developing/bolstering critical substratesDeveloping/bolstering critical substrates

ResponseResponse• Activating and implementing the planActivating and implementing the plan

RecoveryRecovery• Restoring normalcyRestoring normalcy

PlanningPlanning• Recognizing risks and vulnerabilitiesRecognizing risks and vulnerabilities

Planning and Preparedness:Planning and Preparedness:

Essential: PPPPPPPPEssential: PPPPPPPP• Failing to plan is planning to failFailing to plan is planning to fail….….

Be Aware of Possible EventsBe Aware of Possible Events• For community For community andand hospital hospital• ““All hazards” approach makes senseAll hazards” approach makes sense

Plan for Most Probable EventsPlan for Most Probable Events• PlanningPlanning more important than a more important than a planplan

Also Plan for Rare but Catastrophic Also Plan for Rare but Catastrophic

How to Prepare for a Pandemic?How to Prepare for a Pandemic?

Preparing for a new flu pandemicPreparing for a new flu pandemic• Focus on previous modern pandemicsFocus on previous modern pandemics

““Evidence based preparedness”Evidence based preparedness”

• Highlighting some hot-button issuesHighlighting some hot-button issues• Not all inclusive, just some things….Not all inclusive, just some things….

All-hazards preparednessAll-hazards preparedness• More “bang for the buck”More “bang for the buck”

Chronic Problems: “10 C’s”Chronic Problems: “10 C’s”

Charge: who?Charge: who? Command and CtrlCommand and Ctrl CommunicationCommunication CoordinationCoordination ConvergenceConvergence

ContaminationContamination Capacity and surgeCapacity and surge CooperationCooperation Chaos/confusionChaos/confusion CISDCISD

Chronic Problems: “10 C’s”Chronic Problems: “10 C’s”

Charge: who?Charge: who? Command and CtrlCommand and Ctrl CommunicationCommunication CoordinationCoordination ConvergenceConvergence

ContaminationContamination Capacity and surgeCapacity and surge CooperationCooperation Chaos/confusionChaos/confusion CISDCISD

Reality of current situationReality of current situation

Many hospitals Many hospitals are notare not prepared prepared Preparedness is contrary to businessPreparedness is contrary to business Hospitals are not Hospitals are not justjust hospitals hospitals Hospitals depend on Hospitals depend on otherother services services Hospitals can be dangerous placesHospitals can be dangerous places

What is “Surge Capacity?”What is “Surge Capacity?”

Pre-planned process to ensure carePre-planned process to ensure care• Must address routine operations, tooMust address routine operations, too

Needed for all services Needed for all services • StaffStaff needed to provide care needed to provide care• StuffStuff needed to provide care needed to provide care• StructureStructure

SpaceSpace to provide care (hospital or OST to provide care (hospital or OST33F)F) SystemSystem of management to direct resources of management to direct resources

Surge Issues: Past LessonsSurge Issues: Past Lessons

Patient volumesPatient volumes• Geometric growth in volumesGeometric growth in volumes

Supply shortagesSupply shortages• Run low on common itemsRun low on common items

Vaccine supply extensionVaccine supply extension• Studies to “stretch” vaccine by dilutionStudies to “stretch” vaccine by dilution

Elective surgery cancellationsElective surgery cancellations• Elective admissions, surgeries curtailedElective admissions, surgeries curtailed

Hospitals are DependentsHospitals are Dependents

MJA 185 #10 S71MJA 185 #10 S71

Surge CapacitySurge Capacity

Trend has been Trend has been awayaway from capacity from capacity• Systems are already running all-outSystems are already running all-out• Surge planning: not good business?Surge planning: not good business?

JIT stocking of suppliesJIT stocking of supplies Casualization of staffCasualization of staff

Non-traditional approaches requiredNon-traditional approaches required

Surge: Doomsayers Say…Surge: Doomsayers Say…

Health care system is: Health care system is: • FragmentedFragmented• CompetitiveCompetitive• Disorganized Disorganized • BrokeBroke• Private Private • At capacity and shrinkingAt capacity and shrinking

How can we How can we possiblypossibly surge? surge?

Capacity and Surge:Capacity and Surge:

Beds are key hospital “service”Beds are key hospital “service”• Staffing to care for bed and its patientStaffing to care for bed and its patient

What goes into providing beds?What goes into providing beds?• More than More than justjust a room with a bed a room with a bed

How do we ensure enough beds?How do we ensure enough beds?• Need to know how many we needNeed to know how many we need• Need to know how to provide enoughNeed to know how to provide enough

Staff: Personnel IssuesStaff: Personnel Issues

Personnel trends: just-in-time staffPersonnel trends: just-in-time staff• Temporary/agency staffingTemporary/agency staffing• Part-time (casual) employeesPart-time (casual) employees• Multiple gigsMultiple gigs

Union Issues?Union Issues? Work hour restrictions?Work hour restrictions?

Staff: Personnel IssuesStaff: Personnel Issues

Current planning assumptionsCurrent planning assumptions• 40% absenteeism!!!40% absenteeism!!!

Range of estimates worldwideRange of estimates worldwide What is the proof?What is the proof?

Why 40% absenteeism?Why 40% absenteeism?

Schools: hardest hitSchools: hardest hit• 20-50% of students out20-50% of students out

Some kids held outSome kids held out• ““Prophylactically” Prophylactically”

• Leads to some closuresLeads to some closures Primary to universityPrimary to university Football, etc cancelledFootball, etc cancelled

• Teacher absenteeism Teacher absenteeism 4x typical as well4x typical as well

Why 40% absenteeism?Why 40% absenteeism?

General Industry in ‘57 and ‘68General Industry in ‘57 and ‘68• About 2-4x usual rate were out sickAbout 2-4x usual rate were out sick• No disruption in industrial productivityNo disruption in industrial productivity• Less margin for this now?Less margin for this now?

Why 40% absenteeism?Why 40% absenteeism?

Hospitals: squeeze from both endsHospitals: squeeze from both ends• Up to 10x normal ILI-like casesUp to 10x normal ILI-like cases

Harder hit than industry at largeHarder hit than industry at large 30-40% staff absent was “nuisance”30-40% staff absent was “nuisance”

Staff: Absenteeism SurveysStaff: Absenteeism Surveys

General Population:General Population:• Range reported 35-50% fits with past dataRange reported 35-50% fits with past data

First Responders:First Responders:• 80% if no vaccine or PPE80% if no vaccine or PPE• 38% if no protection for immediate family38% if no protection for immediate family

Medical workers:Medical workers:• 26% to provide care; 10% to avoid exposure26% to provide care; 10% to avoid exposure• 50% of hospital workers 50% of hospital workers • 28% in one academic medical center 28% in one academic medical center • 46% of health department workers46% of health department workers

Staff: Past Flu AbsenteeismStaff: Past Flu Absenteeism

Health care worker-specific data:Health care worker-specific data:• Canada: (1981) 6% (3x baseline)Canada: (1981) 6% (3x baseline)• Canada: (2005) 16%Canada: (2005) 16%• USA: (2004) 44%USA: (2004) 44%

Staff: Vaccine Staff: Vaccine vsvs. Absenteeism. Absenteeism

Shorter duration of sick leaveShorter duration of sick leave Lower attack rates if immunizedLower attack rates if immunized Not proven “cost effective”Not proven “cost effective” May offer other benefit: reassuranceMay offer other benefit: reassurance

• All of this assumes folks will get shots!!!All of this assumes folks will get shots!!!

Staff: Mitigation & AbsenteeismStaff: Mitigation & Absenteeism

School closures proposed to slow fluSchool closures proposed to slow flu• Many years start with young kids firstMany years start with young kids first

Problems with child care Problems with child care • Models predict 30% HCW miss workModels predict 30% HCW miss work

Complicates other staffing issuesComplicates other staffing issues

Stuff: Spending $ for Surge?Stuff: Spending $ for Surge?

HRSA: 500 beds for 1M peopleHRSA: 500 beds for 1M people• Assume 50% to ICU, 50% acuteAssume 50% to ICU, 50% acute• 3 days of supplies3 days of supplies• Assume oxygen beds, suction availableAssume oxygen beds, suction available

$5.5M$5.5M for basics for basics • No 3No 3rdrd/4/4thth generation antibiotics, etc. generation antibiotics, etc.

Stuff: the Cost of the ABCsStuff: the Cost of the ABCs

Ventilators for mass critical careVentilators for mass critical care• Focus of lots of planning and discussionFocus of lots of planning and discussion• Major potential source of costsMajor potential source of costs

Bare-bones $3K to $15K eachBare-bones $3K to $15K each

• Major potential source of controversyMajor potential source of controversy Who gets them: from SNS? in ICU?Who gets them: from SNS? in ICU?

Prior solutions: work on your grip!!!Prior solutions: work on your grip!!!• BVM used in Denmark, after KatrinaBVM used in Denmark, after Katrina

Stuff: Blowback of OutsourcingStuff: Blowback of Outsourcing

Many health care supplies from AsiaMany health care supplies from Asia• Estimate: 80% of consumables for HCEstimate: 80% of consumables for HC

Anybody think of a problem here?Anybody think of a problem here?• ““AsianAsian flu” “ flu” “Hong KongHong Kong flu” “ flu” “ChinaChina flu” flu”

Competition: empty shelves Competition: empty shelves • Even in the best of timesEven in the best of times

Stuff: Business Pan-Flu PlansStuff: Business Pan-Flu Plans

Many businesses use Many businesses use Just-in-timeJust-in-time• Low stocking levelsLow stocking levels• Problems reverberate up the systemProblems reverberate up the system

Can we get food, drugs, oxygen, etc?Can we get food, drugs, oxygen, etc?

Space: Alternate Site SurgeSpace: Alternate Site Surge

New concept in surge capacityNew concept in surge capacity Several possible functions/benefitsSeveral possible functions/benefits

• Protect the main facilityProtect the main facility• Provide medical care and shelterProvide medical care and shelter

Have been used with some successHave been used with some success• 1957 flu in NYC1957 flu in NYC• Houston floods, Katrina evacuees Houston floods, Katrina evacuees

Systems Issues: TriageSystems Issues: Triage

The worried well and walking woundedThe worried well and walking wounded• Vastly outnumber those really sickVastly outnumber those really sick

9:1 during 9/11/2001 9:1 during 9/11/2001 500:1 during anthrax!500:1 during anthrax!

• Survey: 1/4 have no one to care for themSurvey: 1/4 have no one to care for them High-risk groups even worseHigh-risk groups even worse

Problems of over-triage Problems of over-triage • Increased mortality in most critically ill/injuredIncreased mortality in most critically ill/injured• Over-worked staff at higher riskOver-worked staff at higher risk

Anes Clinics 25: 161-777Anes Clinics 25: 161-777

Systems Issues: EthicsSystems Issues: Ethics

Disasters Demand ChangesDisasters Demand Changes• In systems of careIn systems of care• In familiar moral and ethical “codes” In familiar moral and ethical “codes”

Key Issues for the hospitalKey Issues for the hospital• Providers: safety vs. responsibilityProviders: safety vs. responsibility• Triage: Triage: equitablyequitably giving giving unequalunequal care care• Ethical preparation: policies in placeEthical preparation: policies in place• Preparation ethic: an obligation?Preparation ethic: an obligation?

Systems Issues: EthicsSystems Issues: Ethics

Other dilemmasOther dilemmas• SafetySafety

Concerns of providers vs. patient needsConcerns of providers vs. patient needs

• Community mitigationCommunity mitigation Quarantine? Quarantine? Masks, social distancing, hygiene, etc.Masks, social distancing, hygiene, etc.

• International issuesInternational issues Travel/borders/immigration?Travel/borders/immigration? Trade?Trade? Sharing resources with other nations?Sharing resources with other nations?

Systems Issues: LegalSystems Issues: Legal

EMTALA EMTALA Altered standard of care?Altered standard of care?

• When?When?• For whom? For whom?

Sanctions for work refusal by HCWs?Sanctions for work refusal by HCWs?• Already in place in several statesAlready in place in several states

License revocation, fines, imprisonment!License revocation, fines, imprisonment!

• Does ability equate with obligation?Does ability equate with obligation?• Do social obligations require risk taking?Do social obligations require risk taking?• Can expectations be enforced?Can expectations be enforced?

Systems issues: Systems issues: CommunicationCommunication

Controlling emotionsControlling emotions• Outbreak vs. epidemic vs. pandemicOutbreak vs. epidemic vs. pandemic

Bring the whole familyBring the whole family• The infamous “two-fer”The infamous “two-fer”

Keeping kids homeKeeping kids home• High attack rates in schoolsHigh attack rates in schools

Rest, fluids, antipyretics: Rest, fluids, antipyretics: educationeducation• Huge predominance of outpatient casesHuge predominance of outpatient cases

Systems Issues: RecoverySystems Issues: Recovery

Recovering issues:Recovering issues:• What about those who refused to work?What about those who refused to work?• Will patients trust the standard of care?Will patients trust the standard of care?

All plans should address recoveryAll plans should address recovery• Transparency may help retain trustTransparency may help retain trust• Pre-planning helpsPre-planning helps

Key Points:Key Points:

Pandemics Will Happen!Pandemics Will Happen!

Planning is as important as the plan!Planning is as important as the plan!

We are expected to be ready!We are expected to be ready!