Pandemic Influenza

Pandemic Influenza Disaster Preparedness and Planning

Present by: Nicole Berard Walden University April, 2012

Hello, My name is Nicole Berard. This is a power point presentation to inform hospitals, outpatient clinics, pre-hospital environments, nursing homes, assisted living centers, and private home healthcare facilities about pandemic influenza preparedness. According to OSHA, (2007), an influenza pandemic may have a global impact and may require a large-scale response that has the potential to quickly overwhelm hospitals and healthcare system regionally and nationally(p. 36). Because of the great impact, pandemic influenza planning should be initiated and should address internal continuation of care and coordination of services with local, state, and federal healthcare agencies.

In this presentation, I will include a brief history of pandemic flu including the impact, clinical presentation of seasonal flu, clinical presentation of past pandemic flu, future pandemics, H5N1 diagnosis, transmission, treatment and prevention, healthcare facility responsibilities before a pandemic, during the pandemic, recovery and preparation for future pandemic waves, and disaster plan.1History Documented influenza pandemics1918195719682009

During the 20th century, there have been 4 documented influenza pandemics (Centers for Disease Control and Prevention, 2011a). I will go into greater detail for each pandemic and the impact, but for now, I will discuss the year for each. The first documented influenza pandemic occurred in 1918. The next pandemic occurred almost 40 years later in 1957. The following occurred shortly after in 1968. The most recent influenza pandemic, which occurred almost 50 years later, was in 2009. It is predicted that another influenza pandemic is highly likely, if not inevitable (CDC, 2011b, para. 4).2Impact1918- 40 million deathsAverage life span depressed1957- 20 million deaths1968- 1 million deaths2009- 8,900 to 18,300 deaths

On this slide, I will discuss the impact that each of the pandemics had on both the U.S. and worldwide. According to the Centers for Disease Control and prevention, (2011a), the impact of an influenza pandemic can be devastating (para. 4). In 1918, the pandemic claimed the lives of almost 40 million people worldwide with approximately 675,000 deaths in the U.S. If one were to look at this in a different perspective, this would suggest that 20-40% of the population worldwide became sick , and it is noted that this decreased the average lifespan in the U.S by 10 years. In 1957, the influenza pandemic deaths included approximately 2 million people worldwide and almost 69,000 people in the U.S. The pandemic of 1968 claimed the lives of nearly 1 million people worldwide and 33,000 in the United States. The most recent pandemic in 2009 caused approximately 8,900 to 18,300 deaths, which is a drastic decline since 1918. By reviewing this information, one can conclude that pandemic pre-planning is essential in order to keep morbidity, mortality, and social disruption to a minimal (CDC, 2011a).ReferencesCenters for Disease Control and prevention. (2011b). CDC Resources for Pandemic Flu. Retrieved from http://www.cdc.gov/flu/tools/fluaid/

Centers for Disease Control and Prevention. (2011b). Notice to readers: Revised estimates of the public health impact of 2009 pandemic influenza a (H1N1) vaccination. Morbidity and Mortality Weekly Report (MMWR). 60 (38). Pp. 1321. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6038a7.htm?s_cid=mm6038a7_x

Centers for Disease Control and Prevention. (2007). Guidelines for Pandemic Emergency Preparedness Planning:A Road Map for Courts. Retrieved from http://www2a.cdc.gov/phlp/docs/Judiciary%20-%20BJA%20Road%20Map%20for%20Courts.pdf

3Clinical PresentationUseful to be aware of clinical manifestations

SymptomsFeverChillsFatigue Muscle achesHeadacheDry coughUpper respiratory congestionSore throat

DurationUp to 2 weeks

On this slide, I will discuss possible signs and symptoms of influenza that should monitored and reported. It is particularly useful for healthcare providers to be aware of the clinical manifestations of the influenza virus so that they can act quickly and prevent further spread (OSHA, 2009). As noted by HHS, 2005 (as cited by OSHA, 2009), seasonal influenza usually has an abrupt onset, with symptoms of fever, chills, fatigue, muscle aches, headache, dry cough, upper respiratory congestion, and sore throat (p.8). The onset is on average 2 days from the time of exposure and usually last 2-7 days with weakness and cough lasting up to 2 weeks.ReferencesOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

4Clinical Presentation Past Pandemic Influenza1918 influenza pandemic manifestations

1957 and 1968 influenza pandemic manifestations

Can occur in waves

6-8 week period

On the last slide, I discussed the clinical manifestations along with signs and symptoms of seasonal influenza. Here, I will discuss the clinical presentation of recent pandemic influenza so that one will be able to better identify future pandemics. The sooner we identify a new pandemic, the sooner we can take steps to isolate cases and initiate measures to prevent the spread and protect the community and healthcare workers (OSHA, 2009). With the 1918 influenza pandemic, the signs and symptoms had a much greater severity than seasonal flu and affected mostly healthy adults between the ages 15-35. Patients developed the disease suddenly and were noted to have perioral cyanosis. In 1957 and 1968, the symptoms were like that of seasonal flu but milder compared to the 1918 pandemic. In 1957, the pandemic, was noted to cause complications such as viral pneumonia. So as one can see, each pandemic presented with different clinical manifestations.

Influenza Pandemics Can occur in waves that last from 6-8 weeks. According to Billings, 2005, (as cited by CDC, 2007), this means that the virus could spread rapidly during the 6-8 week period, appear to be on the decline, then reoccur and continue to rise and decline until it is finally contained. (CDC, 2007). Occupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf2. Centers for Disease Control and Prevention. (2007). Guidelines for Pandemic Emergency Preparedness Planning: A Road Map for Courts. Retrieved from http://www2a.cdc.gov/phlp/docs/Judiciary%20 %20BJA%20Road%20Map%20for%20Courts.pdf

5Future PandemicsH5N1 and H7N7 H5N1Population affectedSymptomsLaboratory resultsTransmissionH7N7Manifestations Transmission

The greatest concern for future pandemics is the H5N1 and H7N7 influenza strand (OSHA, 2007). Both are avian influenza viruses that are highly pathogenic. H5N1 influenza virus has caused outbreaks in Hong Kong, Thailand, Vietnam, and Cambodia and mainly affected children and young adults. Patients that were hospitalized and diagnosed with H5N1 developed the classic flu symptoms but instead had lower respiratory tract symptoms, had shortness of breath and developed viral pneumonia. In addition, unlike regular seasonal flu, these patients also had diarrhea, abdominal pain, and vomiting. Some of the common laboratory findings were lymphopenia, thrombocytopenia, and elevated aminotransferase levels and often had higher ribonucleic acid detection (OSHA, 2007, p. 9). According to OSHA, (2007), H5N1 can be transmitted via respiratory secretions and questions arise on whether it may be transmitted by contact with blood.

As noted by Du Ry et al., 2005 (as cited by OSHA, 2007) an avian influenza virus (H7N7) outbreak occurred in poultry farm employees, in the Netherlands, in 2003 (p. 12). This outbreak was associated mainly with conjunctivitis which suggests that the transmission may occur via the mucous membranes of the eye.ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

6H5N1 Diagnosis4-Hour RT-PCR assayDistributed in all 50 statesClinical manifestations to performReporting resultsConfirming results

Because of the great importance that H5N1 could be the possible cause of the next influenza pandemic, I will discuss how one would identify H5N1. According to OSHA, (2007), H5N1 avian influenza virus is considered to have the greatest potential for mutation to a pandemic virus given how widespread the virus is and because it has already caused illness and death in people (p.11). It has spread rapidly in areas such as Asia, Europe, and Africa via birds. According to MMWR, 2006 (as cited by OSHA, 2007), HHS/CDC has recently developed a 4-hour RT-PCR assay. This will aid in the detection of the gene coding for the H5 surface protein of the H5N1 avian influenza virus. These reagents have been distributed to various laboratories within all 50 states. This test should be performed if a patient presents with severe respiratory illness and clinical or epidemiological risk (OSHA, 2007, p. 11). If H5N1 is suspected, this should be reported to local or states health departments as soon as possible and should be confirmed by HHS/CDC.ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

7Future Pandemic Treatment/PreventionAntiviral drugs

Vaccinations

Here, I will discuss the use of antiviral drugs and vaccinations during an influenza pandemic. Antiviral drug use during a pandemic may help to minimize the associated morbidity and mortality (OSHA, 2007). The use of antiviral drugs should be started as early as possible to be effective. The only problem with antiviral drug use is that the availability of a specific antiviral drug during a pandemic is not guaranteed, therefore, should be given to priority individuals first. HHS pandemic influenza plan includes priority group recommendations.

Vaccinations for specific pandemic influenza may take some time after the pandemic begins before availability (OSHA, 2007). As noted by OSHA, (2007), Vaccinations against seasonal influenza during the WHOs Interpandemic and Pandemic Alert Period can reduce co-infections and might ameliorate pandemic effects (p. 13).

ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

8Disaster Preparedness For an Influenza PandemicSupport of Healthcare worker staffDefine essential staff and servicesInformation technology and Public Health CommunicationsSurveillance and protocolsTrainingSecurity

Because of the great impact an influenza pandemic can have worldwide, it is crucial to discuss disaster preparedness for future influenza pandemics. Disaster preparedness may include: Support of healthcare workers and employees, defining key staff and services, information technology and public health communications, surveillance and protocols, training, and security. I will discuss each of these areas in the following slides.

ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

9Homeland Security Council StagesStages 0-1Before PandemicStages 2-5During PandemicStage 6Recovery and Preparation for subsequent pandemic wavesHere, we will discuss the different stages of an influenza pandemic. Homeland Security Council (HSC) National Strategy for Pandemic Influenza Implementation Plan has developed different stages and actions for each stage. These stages include: Stages 0-1 (Before a pandemic occurs), Stages 2-5 (During the pandemic), and Stage 6 (Recovery and Preparation for Subsequent Pandemic Waves). Each of these stages will be discussed in the following slides.. ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

10Healthcare Facility Responsibilities Before a Pandemic Stages 0-1Be preparedInitiate planning and decision making strategiesRecognize deficienciesBecome familiar with local, state, and federal health agenciesBecome familiar with security agencies

According to HSC, stages 0-1 are designated as before a pandemic occurs (OSHA, 2007). As noted in previous slides, it is necessary for healthcare facilities to be prepared in advance to respond to potential influenza pandemics. Planning and decision making strategies should be initiated and include a multidisciplinary approach. It is essential to identify the individuals within your organization who will be responsible for coordinating communication, integrating public health recommendations, establishing security, and developing a written plan (OSHA, 2007, p. 36). It is necessary to recognize deficiencies such as staffing shortages or lack of written guidelines (OSHA, 2007, p. 38). One should also make you and your agency familiar with local, state, and federal health and security agencies and how to access information and supplies. It is an excellent idea to establish hotlines and websites to communicate effectively and develop communication services accessible to those with disabilities.ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

11Before a Pandemic contDevelop Written Plans

Here, Stages 0-1 is continued , and I will now focus on written plans. Written plans should be developed and readily available in the case of future influenza pandemics. The written plan should be set for each facility and community and should include: Disease surveillance, isolation and quarantine practices, hospital capacity criteria, hospital communication, staff education and training, triage, clinical evaluation and diagnosis, security, facility access, facility infrastructure (e.g., isolation rooms), occupational health for employees, use and administration of vaccines and antiviral drugs, facility surge capacity (e.g., durable and consumable supplies), supply chains (purchase, distributions and transportation of supplies), access to critical inventory supplies, and mortuary issues (e.g. storage capacity) (OSHA, 2007, p. 36).ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

12Before Pandemic contWork with CommitteesParticipate in exercises and drills

Continuing with Stages 0-1, it is also a smart idea to work with emergency planning committees at local, state and national levels. This will help to integrate with community, state, and national pandemic plans and training (OSHA, 2007, p.36). This will help to identify community volunteer and available medical support professionals (OSHA, 2007, p. 39). This can be performed by your Human Resources department along with planning for health and compensation concerns that may arise from workers. It is also recommended participating in response exercises and drills and to incorporate the lessons learned into your pandemic response plan.

ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

13Healthcare Facility Responsibilities During the PandemicStages 2-3Confirmed human outbreaks overseasSurveillancePrepare to implement planStages 4-5Begins in or Enters the United StatesActivate plansSurveillanceIdentify and isolateSurge capacity plansInfection ControlCommunicationReporting

Occupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

The following Stages are during the influenza pandemic and include stages 2-5. As noted by OSHA, (2007), stages 2-3 are confirmed human outbreaks overseas (p. 37). At this point, it is vital to raise surveillance of patients and staff for flu-like symptoms and contact local, state, or federal agencies with any issues and for recommendations. At this point, one should also prepare to implement your pandemic influenza plan.

Stages 4-5 is if pandemic influenza begins in or enters the United States (OSHA, 2007, p. 37). At this point, one should activate your pandemic influenza plan, intensify surveillance and identify possible pandemic influenza patients, implement surge capacity plans to sustain healthcare delivery, implement infection control practices to prevent the spread and monitor for nosocomial transmission, ensure rapid and frequent communication within and between healthcare facilities, health departments and federal government, and make sure that there is a system for reporting cases and deaths (OSHA, 2007, p. 36).ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

14Healthcare Facility Recovery and Preparation for Subsequent Pandemic WavesStage 6Continue surveillanceReturn to normal operationsReview planIdentify issuesKeep communication open

The last HSC stage is stage 6 and includes the recovery after an influenza pandemic and preparation for future pandemic waves. This stage would include continuing surveillance for those with flu-like symptoms. At this point, it is advisable to return to normal facility operations as soon as possible (OSHA, 2007, p. 37). One would also need to look over your pandemic influenza system based on the pandemic wave, see what worked and what did not work and incorporate this in future planning for future pandemic waves. It is necessary to identify any issues one may have had with obtaining supplies or resources. One may also want to keep the lines of communication open between facilities, health departments, and government to be able to identify subsequent waves. ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

15General Pandemic ResourcesDepartment of Health and Human Serviceshttp://www.pandemicflu.gov http://www.pandemicflu.gov/plan/tab6.html

Centers for Disease Control and Preventionhttp://www2a.cdc.gov/od/fluaid http://www.cdc.gov/flu/flusurge.htm Here, I have provided two free resources that one may access. The first is The Department of Health and Human Services and the second is Centers for Disease Control and Prevention. Both resources support multiple websites that will give one access to available information, resources, and checklist which are printer friendly.

Department of Health and Human services website (http://www.pandemicflu.gov) includes Federal/State pandemic disaster planning resources and is updated as new information becomes available (OSHA, 2007, p. 52). The following website is http://www.pandemicflu.gov/plan/tab6.html and includes checklists for specific healthcare services, hospitals, clinics, home health, long-term care, and EMS (OSHA, 2007, p. 52).

Centers for Disease Control and Prevention provides two educational websites. The first I have included is http://www2a.cdc.gov/od/fluaid. This is a website for the FluAid program which is a resource for state and local planners to estimate range of deaths, hospitalizations, and outpatient visits for a community (OSHA, 2007, p. 52). A second website provided by CDC is http://www.cdc.gov/flu/flusurge.htm. This is a website for the FluSurge program which estimates the impact of a pandemic on the surge capacity of individual healthcare facilities, (i.e., hospital beds, ventilators) (OSHA, 2007, p. 52).ReferenceOccupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

16ConclusionInfluenza pandemic = worldwide devastationRecognize clinical manifestations and trendsProper planning and preparednessResources available

As I have mentioned, influenza pandemics can create immense distress worldwide. Because of this, it is essential to recognize the clinical manifestations of seasonal influenza, but more importantly to identify the trends and onset of a new influenza pandemic. The quicker we identify a new pandemic occurring, the quicker we can move and prevent the spread and potential significant impact. Through proper planning and preparedness, we can reduce the morbidity and mortality associated with future influenza pandemics. As I have mentioned, there are numerous resources on the Web and through your local and state health departments that are available to better serve you with disaster preparedness and planning.

I would like to thank everyone for your time and before closing, I would like to allow some time for those of you who may have questions, concerns or comments, please raise your hand , and I will respond accordingly.

17ReferenceCenters for Disease Control and prevention. (2011a). CDC Resources for Pandemic Flu. Retrieved from http://www.cdc.gov/flu/tools/fluaid/

Centers for Disease Control and Prevention. (2011b). Notice to readers: Revised estimates of the public health impact of 2009 pandemic influenza a (H1N1) vaccination. Morbidity and Mortality Weekly Report (MMWR). 60 (38). Pp 1321. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6038a7.htm?s_cid=mm6038a7_x

Centers for Disease Control and Prevention. (2007). Guidelines for Pandemic Emergency Preparedness Planning: A Road Map for Courts. Retrieved from http://www2a.cdc.gov/phlp/docs/Judiciary%20-%20BJA%20Road%20Map%20for%20Courts.pdf

Occupational Safety and Health Administration U.S. Department of Labor (OSHA). (2009). Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers. Retrieved from http://www.osha.gov/Publications/OSHA_pandemic_health.pdf

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