Unit 13: Pandemic Scenario Rick Bissell, PhD Tom Kirsch, MD, MPH

Unit 13: Pandemic Scenario

Rick Bissell, PhD

Tom Kirsch, MD, MPH

Catastrophe Readiness and Response CourseSession 13

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Learning Objectives

• By the end of this session (readings, lectures and exercises) the student should be able to:

• Describe mechanisms of disease spread and control.

• Describe the current estimates of the social, economic, transportation, communications and health sector impacts of a pandemic, and their affects on critical systems (e.g. food, utilities, law enforcement, healthcare, etc.).

• Describe current federal pandemic preparedness and response plans.


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Learning Objectives - 2

• Identify potential strategies for dealing with/ responding to a pandemic.

• Describe barriers to effective inter-jurisdictional planning for pandemic response.

• Discuss the impact of a pandemic on the private sector.

• Discuss the potential long range economic problems that may result from a pandemic.

• Discuss inter-jurisdictional issues (including international coordination) in a pandemic response.


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Vocabulary Reviewfrom Session 7

• Public health: Use of the sciences of epidemiology, medicine, sociology, microbiology and health education to investigate and protect the health of a population.

• Epidemiology: The discipline within public health that investigates the causes and pathways of diseases and injuries, as well as their distribution within a population.


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Vocabulary Reviewfrom Session 7 - 2

• Surveillance: The monitoring of behavior, in this case the behavior (infection pattern) of an infectious disease.

• Pandemic: An epidemic that affects the entire world, or substantial portions of it.– e.g. the 1918 Influenza pandemic

• Etiology: The causes and pathway of a disease. – e.g. the bacteria or virus, its incubation period, the

ways it propagates and enters the body, etc.


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Disease Control Mechanisms

• Disease control:– Epidemiologic investigation to determine

causes, mechanisms of spread, extent of spread.

– Vaccination, use of medication to induce herd immunity, treatment of ill individuals.

– Social distancing, quarantine, isolation, reducing vectors.

– Treatment of individuals to reduce their infectivity (ability to spread the infection).


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Review

• Public Health and epidemiology are scientific methods to prevent or reduce the spread of illness in a population.

• Endemic and epidemic infectious diseases are the leading cause of death worldwide.

• There are specific tools used to reduce the spread of infections.

Pandemic Influenza


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Why Do We Care?

• Historically pandemics have killed millions and destroyed entire societies:– The Black Plague in Europe in the Middle

Ages killed as much as 50% of the entire population, and wiped out entire communities.

– The 1918 Influenza Pandemic killed more than 20 million people worldwide in less than a year, some now estimate that it was 100 million.Gina Koleta: Flu, The Story of the Great Influenza Epidemic of 1918 and the Search for the Virus that Caused It. ISBN-10: 1417618019


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Influenza

• A virus that causes predictable, seasonal (winter) epidemics.

• Not a ‘cold’, but an infection with high fevers and muscle aches. It can lead to pneumonia and death.

• There are an estimated 20,000 deaths from influenza each year in the USA, usually among the elderly and immunocompromised. www.cdc.gov/flu/nivw06.htm


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Pandemic Flu Scenario

• Each year the influenza virus mutates slightly so that it is different enough to infect even people who were infected before and are immune to the ‘old’ virus.

• Occasionally the virus mutates greatly and becomes more deadly and a “novel” flu virus to which almost nobody has immunity (e.g. the 1918 Pandemic).


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Pandemic Flu Scenario - 2

• The influenza virus lives in humans, birds and some mammals.

• The H5N1 virus is widely endemic in birds and has the potential to become a very deadly pandemic in humans.

• Spreads via waterborne droplets, close contact, and fomites.

• The most common cause of spread is dirty hands.


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• When H5N1 spreads to humans (usually directly from birds) the case fatality rate (2008) is over 50%.

• There is no vaccine for a novel virus; it takes a minimum of 4-6 months to produce a vaccine, longer to produce a large quantity.

• H5N1 is showing resistance to some current antiviral medications.

» CDC: www.pandemicflu.gov/vaccine/index.html


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• Potential Effects in the USA:– Deaths ranging from the hundreds of thousands to

many millions.– The pandemic could last 3-9 months, or more, likely

coming in 2 to 3 waves.– Demand for medical care would vastly overwhelm all

available resources.– Up to 40% of essential services employees may not

show up to work, including: medical/health care, law enforcement, food transport and grocery stores, school personnel, fire/rescue, etc. www.pandemicflu.gov/plan/pandplan.html


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• Potential Effects in the USA, cont.– Lawlessness may break out related to a lack

of access to basic services and resources.• Cities may be particularly hard hit if food resources

become limited.

– Banking and financial services may be restricted or cease to function.

– People with many non-influenza-related health conditions may find it difficult to obtain medical care or medications.


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• All, or virtually all US jurisdictions will be affected, therefore:– Mutual aid is unlikely, however:– Sharing of resources may be more necessary

than ever before.– Competition between jurisdictions is a real

possibility.– All response coordination must be multi-

jurisdictional and multi-level.


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Class Exercise 1

• Before going any further, break into groups and discuss what the challenges will be for emergency managers, and what functions EM can play in responding to a pandemic. Groups report back to the larger class. Consider areas such as:


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Class Exercise 1, cont.

• Communications

• Equipment

• Supplies

• Personnel

• Safety/security

• Population fears

The Principles of Pandemic Response


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Principles of Pandemic Response 1

• WHO Alert Phases for Avian Influenza:

1 Low risk of human cases

2 Higher risk of human cases

3 Not any, or very limited human-to-human transmission

4 Evidence of increased human-to-human transmission

5 Evidence of significant human-to-human transmission

6 Efficient and sustained human-to-human transmission

Source: http://www.pandemicflu.gov/faq/pandemicinfluenza/1123.html


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Principles of Pandemic Response -2

• Needs assessment:

– 3 realms of concern:• Control of the pandemic• Meeting other health care needs• Basic societal requirements


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Principles of Pandemic Response - 3

• First and foremost: “Scene” safety!!!– Research has shown that a significant percentage of

health care workers, and, by extension, other priority personnel who will come in contact with the public, such as law enforcement, will not come to work in a pandemic out of fear of self contamination or contamination of their families. Plans will need to be made to provide protection to these personnel, or very little else will go according to plan.http://emergency.cdc.gov/cerc/pdf/CERC-PandemicFlu-OCT07.pdf


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• Control of the Pandemic– Epidemiologic surveillance and updating.– Institution of prevention: social distancing,

quarantine, isolation (who takes care of these people?).

– Distribution of vaccines and meds (how to distribute and to whom?).

– Surge/overflow: where, and with what health care workers?

– Family-centered self-care information.


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• Other health care needs– How to meet routine care and normal

emergency care needs when hospitals are overflowing, and health care workers are absent?

– How to encourage health care workers to return to work?

– How to keep supplies available in a system that depends on just-in-time deliveries?


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• Basic societal needs– Law enforcement– Food deliveries– Fuel deliveries– Utilities– Monetary system– Power plants– Continuity of government

• How to prioritize among competing needs?


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Overview of Federal Plans

• Two lead agencies: – Department of Health and Human Services

(DHHS, also called HHS), including the Centers for Disease Control and Prevention (CDC), the Public Health Service (USPHS) and the HHS Office of the Assistant Secretary for Preparedness and Response.


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Overview of Federal Plans - 2

• Second lead agency:– Department of Homeland Security (DHS),

particularly the Office of Health Affairs, which is directed by the Assistant Secretary/Chief Medical Officer.

• Many federal support agencies


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“Plans are nothing, Planning is everything”

General Dwight D. Eisenhower


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HHS Pandemic Flu -1

• HHS will collaborate with the World Health Organization (WHO) and other nations in all related pandemic flu efforts.

• The HHS plan assumes high importance for preparedness at all jurisdictional levels, as well as cross-agency, multi-jurisdictional response efforts designed to strengthen local response effectiveness.


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HHS Pandemic Flu Plan - 2

• Major components of the critical preparedness and ready response actions include:– Intensifying surveillance and collaborating on containment

measures – both international and domestic;– Stockpiling of antivirals and vaccines and working with industry

to expand capacity for production of these medical countermeasures;

– Creating a seamless network of federal, state and local preparedness, including increasing health care surge capacity; and

– Developing the public education and communications efforts that will be so critical to keeping the public informed.


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• Preparedness plan based on:– Funding to state health departments with

planning requirements, some of which must go to county/city health departments.

– Provision of required forms that need to be filled out by jurisdictions, demonstrating planning accomplishments.

– CDC-funded evaluation teams.– Some money for exercises.


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• HHS Response Plan based on:• Federal roles:

– Provide definitive reference labs and epidemiologic surveillance/information

– Provide Strategic National Stockpile (SNS) of pharmaceuticals, vaccines and other critical medical supplies and equipment

– Coordinate distribution to states of key medical supplies and personnel

– Coordinate with international agencies


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• State roles in HHS plan:– Coordinate delivery of Stockpile to counties

and cities– Provide front-line pathology labs– Coordinate health sector response within the

state– (In some states) State health departments

serve as the lead response agency for the duration of the pandemic.


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• State roles, continued– Coordinate flow of medical supplies and

personnel.– Coordinate designation of alternate treatment

sites.– Coordinate placement of those needing

treatment.– Work with counties/cities in the designation of

quarantine and isolation sites, and provide enforcement where necessary.


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• State roles, continued– Revise, amend, suspend state laws

addressing quarantine/isolation and medical practice codes.

– Report epi findings back to CDC and request targeted assistance from HHS

– Provide state law enforcement manpower where local law enforcement may fall short on protecting vital sites and functions.


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• County/city roles– Prioritize use of local health care resources

among competing interests.– Receive, store, distribute SNS supplies.– Provide law enforcement for key sites and

services.– Establish/enforce quarantine/isolation.– Set up/maintain alternate treatment sites.


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• County/city roles, continued– Coordinate coroner and mortuary operations.– Provide home care information to the public.– Provide/ coordinate vaccine distribution.– Coordinate distribution of food supplies where

needed.– Provide epi findings to state health

department.


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Department of Homeland Security (DHS) Pandemic Plan -1

• Pillars of pandemic preparedness are:– Preparedness and communication– Surveillance and detection– Response and command

• Goals– Limit spread and damage– Protect commerce and infrastructure– Assure governmental and economic continuity


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• Preparedness– State and community level planning– Build SNS and distribution plan– Build national vaccine production capacity– Work with WHO and other international orgs– Build and exercise plans at all levels of gov.– Plan for medical and veterinary surge

capacity


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• Surveillance and response:– Similar to HHS plan, with the exception of a

section on sustaining infrastructure, critical services and the economy.

• Roles and Responsibilities:– Lead technical roles: DHHS and Dept. Ag.– Lead federal coordination: DHS


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Barriers -1

• Most funding is “stovepiped” to either emergency management or health, but not to both. Funding for non-governmental partners is virtually nil. Funding to one jurisdiction is not shared with others.

• In many jurisdictions, EM and health rarely include each other in planning and exercises.

• Many emergency managers express some angst at dealing with health authorities.


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Barriers - 2

• Many decision-makers in the health sector are poorly informed about emergency decision-making or the national emergency management systems.

• Public health personnel tend to make decisions in a slow-moving democratic fashion based on data collection and analysis.


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Barriers - 3

• Despite guidance from the CDC and other agencies, many health jurisdictions simply do not have anyone with emergency planning expertise, and do not conduct serious pandemic planning.

• Mechanisms for the US to receive international aid are still poorly developed and conflictive.


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Potential Long-Range Problems -1

• Both short- and long-term economic losses due to loss of employees at all levels of economic activity.

• Possible surplus of housing leading to more financial loss in this market.

• Significant disruption of education, training systems, and career development.


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Potential Long-Range Problems - 2

• Potential threat to continuity of the democratic form of government if martial law is needed during the pandemic (See Session 5).

• Health care resources spent in the pandemic may significantly decrease resources available to other health and social issues.


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Capstone Discussion or Writing Assignment

• Now that you have reviewed the pandemic scenario and have some familiarity with the federal plan/approach:– What is missing in the current preparedness

efforts?– What roles/interventions/responsibilities

should EMs take in both the preparedness and response stages of a pandemic?

– How does pandemic preparedness contribute to bioterrorism preparedness?

Documents

Unit 13: Pandemic Scenario Rick Bissell, PhD Tom Kirsch, MD, MPH