Pandemic Flu Preparedness and Update

1. Pandemic Flu Preparedness and Update April 30, 2009

2. Today’s Presenters: • Al Cook, CMRP, FAHRMM Chief Resource Director The Regional Medical Center • Jeff Wagner, CMRP Vice President MidMichigan Health

3. Pandemic Guidelines

4. Pandemic Guidelines

5. Pandemic Guidelines

6. Pandemic Guidelines

7. Medical Materials Coordinating Group(MMCG) • The MMCG is a subgroup of the Healthcare Sector Coordinating Council (HSCC), which itself is comprised of fifteen owner-operators and association members which represent the medical products supply chain – including manufacturers, consolidators, distributors, and maintenance and repair. • The HSCC and MMCG are recognized by the Department of Homeland Security and other federal agencies as the initial point of contact within healthcare’s private industry for critical infrastructure protection, preparedness, and response purposes.

8. Healthcare Sector Coordinating Council (HSCC) The HSCC is comprised of representatives and alternates from each sub-council. Issue will be identified by Subcouncils. Coordination across Subcouncils and with the GCC will be organized through the HSCC. Each sub-council is responsible for organizing itself Sample Priority Issues for Sub-Councils: Emergency Preparedness, Emergency Response; Vulnerability Assessment / Prioritization; Communication & Information Sharing among members, with HHS and DHS, and with other sectors Cross-cutting Work Groups will be established to address priority issues that cut across sub-councils Healthcare Personnel Includes: Doctors, nurses, pharmacists, dentists, emergency medicine and other clinicians and practitioners with direct involvement in healthcare delivery Insurers, Payers, HMOs Includes: Representatives of third-party payers for medical treatment and healthcare delivery including insurance companies, HMOs and others • Information Technology • Includes: • All IT systems, capabilities and networks supporting delivery of healthcare services Laboratories and Blood Includes: Laboratories and lab support services separate from medical treatment facilities, and companies and associations from the blood, tissue and organ industry Mass Fatality Mgt Services Includes: Medical examiners, coroners, funeral directors, cremationists, cemeterians, clergy, and manufacturers and distributors of funeral, memorial, and cremation supplies Medical Materials Coordinating Includes: Manufacturers, suppliers, and distributors of medical supplies and equipment, as well as health care materials managers Medical Treatment Includes: Hospitals, clinics, and other organizations/ entities that deliver medical treatment Occupational Health Includes: Occupational health physicians and nurses, industrial hygienists, and other occupational health professionals Pharma and Biotech Includes: Manufacturers, suppliers and distributors of generic and branded pharmaceuticals and biological equipment Healthcare and Public Health Sector Government Coordinating Council (GCC) AHRQ CDC CMS FDA HRSA IHS/TRIBAL NIH SAMHSA DOD VA STATE/LOCAL

9. Manage the Hype • Update | 1:09 p.m. | C.D.C. Briefing • Dr. Richard Besser, the Acting Director of the C.D.C. said that the declaration of a public health emergency in the United States on Sunday "streamlines the process by which the government works." He adds that the government will be giving people coming to the U.S. information on how to avoid getting sick and "out of an abundance of caution" is advising people to forgo any non-essential travel to Mexico at this time.

10. Manage the Hype • Update | 1:16 p.m. | C.D.C. Briefing Dr. Besser says that, for people who run businesses or schools, it is "time to think about" how they might adapt if an outbreak happens on a large scale and they have to make things work with people working or studying from home. He also says that 11 million doses of anti-viral drugs from a government stockpile have been sent to states with cases of the swine flu, including California, Texas and New York. • Update | 1:19 p.m. | C.D.C. Briefing In response to a question from a reporter, Dr. Besser says that wearing masks is generally not as useful as doing things to prevent disease transmission, like washing your hands and forgoing "that little kiss of greeting" between people. Dr. Besser makes the point that the flu is not transmitted by eating pork. • Update | 1:21 p.m. | C.D.C. Briefing A reporter for the Wall Street Journal asks if not having a director of Health and Human Services at the moment has hurt the government's response to this crisis. Dr. Besser says that it has not. He does say that a lack of funds for the public health system, due to cuts in state budgets, could cause problems in the future. He says that "investments in preparedness" is what led to this outbreak being identified in the United States as quickly as it was.

11. Manage the Hype • Update | 1:28 p.m. | C.D.C. BriefingDr. Besser clarifies that the government has only released 25% of the stockpile of anti-viral drugs so far. • Update | 1:35 p.m. | C.D.C. BriefingDr. Besser says, in response to a question, that the decision of the European Union to place a travel restriction on people coming to the United States is "premature," given that "we only know of 20 cases" and just one person has been hospitalized in the U.S. so far. • Update | 1:38 p.m. | C.D.C. BriefingA CNN reporter asks if Dr. Besser's advice to not kiss people as a token of greeting only applies to people in areas where the virus has been identified. He says that the C.D.C. is not calling for "a ban on affection," but suggests people in areas where the virus has been identified should probably pass on kissing each other hello or goodbye for now.

12. Manage the Hype • Update | 1:47 p.m.C.D.C. BriefingDr. Besser's briefing is over, but a good resource is the C.D.C.'s Swine Influenza page on its Web site, which has a lot of information about how to spot the infection, how to avoid getting it, and information on where the 40 confirmed cases in the U.S. have been identified. The C.D.C. site was updated within the last hour to show that cases have been confirmed in the following states: California (7 cases); Kansas (2 cases); New York City (28 cases); Ohio (1 case); Texas (2 cases).

13. Pandemic Influenza Phases In nature, influenza viruses circulate continuously among animals, especially birds. Even though such viruses might theoretically develop into pandemic viruses, in Phase 1 no viruses circulating among animals have been reported to cause infections in humans. In Phase 2 an animal influenza virus circulating among domesticated or wild animals is known to have caused infection in humans, and is therefore considered a potential pandemic threat. In Phase 3, an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people, but has not resulted in human-to-human transmission sufficient to sustain community-level outbreaks. Limited human-to-human transmission may occur under some circumstances, for example, when there is close contact between an infected person and an unprotected caregiver. However, limited transmission under such restricted circumstances does not indicate that the virus has gained the level of transmissibility among humans necessary to cause a pandemic.

14. Pandemic Influenza Phases Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion.

15. Pandemic Influenza Phases Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short. Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way.

16. Pandemic Influenza Phases During the post-peak period, pandemic disease levels in most countries with adequate surveillance will have dropped below peak observed levels. The post-peak period signifies that pandemic activity appears to be decreasing; however, it is uncertain if additional waves will occur and countries will need to be prepared for a second wave. Previous pandemics have been characterized by waves of activity spread over months. Once the level of disease activity drops, a critical communications task will be to balance this information with the possibility of another wave. Pandemic waves can be separated by months and an immediate “at-ease” signal may be premature. In the post-pandemic period, influenza disease activity will have returned to levels normally seen for seasonal influenza. It is expected that the pandemic virus will behave as a seasonal influenza A virus. At this stage, it is important to maintain surveillance and update pandemic preparedness and response plans accordingly. An intensive phase of recovery and evaluation may be required.

17. Calculating demand in a pandemic • OSHA estimates that for healthcare workers, masks will be changed four times per 12 hour shift for direct patient care givers. Most healthcare workers think this is well underestimated. • OSHA also indicates that in Emergency Rooms, direct care givers may use as many as one mask between each patient and that each person visiting the ER should be issued an n-95 to prevent transmission. • The number is staggering and might indicate that in some cases, Materials Managers might be better served to seek reusable alternatives.

18. Considerations for meeting demand for PPE • Initial volume will not be 100% occupancy but will start with a significant surge in daily use and crescendo at full census. • Heightened awareness should be made for the potential of sensitive medical PPE departing with the workforce. • At the onset, estimates of daily use should be calculated and the initial 96 hours of use should be brought on site. • Work with established suppliers and with the work force to establish potential alternatives to disposable N-95 face masks. OSHA site offers several alternative devices. • Assure that the correct type of mask or respirator is used in the most appropriate instance, e.g.: surgical masks used where appropriate and disposable N-95s only used where essential.

19. Resources http://www.cdc.gov/swineflu/ http://www.cdc.gov/swineflu/recommendations.htm http://www.cdc.gov/swineflu/masks.htm http://www.chcoc.gov/Transmittals/TransmittalDetails.aspx?TransmittalID=2227 http://www.osha.gov/Publications/3328-05-2007-English.html#RespiratoryProtectionforPandemicInfluenza

20. Additional Resource AHRMM’s Disaster Preparedness Manual for Materials Management Professionals is carried in the online AHRMM Book Store

21. AHRMM’s Disaster Preparedness Manual • This book offers sound advice in planning and preparing for disaster preparedness. This is the time to engage with local, regional, state and even federal agencies regarding the plans and resources that will be made available to the hospital as a result of those plans. No hospital will stand alone in any disaster response but will stand as a focal point with other local and regional agencies to deliver health and public health services to their respective communities in the most efficient and effective manner. • Now is the time for understanding these resources and how they will all come together to serve the health needs of their communities. Preparation and understanding of these integrated response efforts will be key elements of hospitals’ disaster response plans.

22. Late Breaking News Current level of influenza pandemic alert raised from phase 4 to 5 Based on assessment of all available information and following several expert consultations, Dr Margaret Chan, WHO's Director-General raised the current level of influenza pandemic alert from phase 4 to 5. She stated that all countries should immediately activate their pandemic preparedness plans. At this stage, effective and essential measures include heightened surveillance, early detection and treatment of cases, and infection control in all health facilities.

23. Questions

24. Speaker Contact Information Al Cook, CMRP, FAHRMM Chief Resource Director The Regional Medical Center Orangeburg, SC 803 395 2651 acook@regmed.com Jeffrey J. Wagner, CMRP Vice President MidMichigan Health Midland, MI 989-839-3821 jeff.wagner@midmichigan.org