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Understanding Pandemic Threats and Preparedness Strategies: A Comprehensive Analysis

This presentation by Dr. Gerard Doyle, MD, MPH, delves into pandemic threats, analyzing historical data, the current state of preparedness, and strategies for effective response. It explores defining characteristics of pandemics, potential risks, and lessons learned from events like the 1918 flu and SARS. The importance of planning, community health readiness, and surge capacity in healthcare settings is emphasized, along with methods for ensuring adequate resources during a pandemic. Essential considerations for healthcare systems are highlighted to improve resilience and response capabilities.

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Understanding Pandemic Threats and Preparedness Strategies: A Comprehensive Analysis

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Presentation Transcript

  1. Pandemic Planning Gerard Doyle, MD MPH UWSMPH 3 October, 2008

  2. Topics for the Day: • What are the potential threats? • Where are we? • Where do we need to be? • How do we get there?

  3. Why Should I Care? • It Could Happen • “Even Paranoids Have Enemies” • It has happened: 1918, SARS, etc? • It Could Happen to You • What’s out there? • Sanctions and other penalties? • JCAHO, ACEP, etc.

  4. What Is A Pandemic? • Pandemic occurs when: • New organism appears • Reassorted influenza genes, for example • Human population has poor immunity • Result is simultaneous epidemics • Enormous death and illness worldwide From WHO

  5. Not so long ago….

  6. Are We Overdue? • Pandemic flu • 10-13 since 1700 • SWAG: 3% annual • Effect of H5N1?

  7. Interpandemic Period Phase 1: No new human virus Phase 2: No new human virus Animal virus Substantial risk Pandemic alert period Phase 3: New subtype No human-to-human Phase 4: Small clusters Limited spread Virus not adapted Phase 5: Larger clusters Virus better adapted Substantial risk Pandemic period Phase 6: Pandemic Sustained transmission WHO Pandemic Flu Phases

  8. How Bad is the Big Bad Wolf? • Mortality rates of prior flu pandemics • 1918: 2.5% case fatality rate • 1957 and 1968 were not as bad as 1918 • Are we different today? • Populations density much higher • Travel much easier and faster • More people are chronically ill • Are current plans’ predictions valid? • What can we learn from the past?

  9. National Pandemic Flu Plan • HHS convened panel in 2005 • State and local health officials • Funding and some guidance, but…. • YOYO for up to a month? • Local/private agencies bear the burden

  10. Disaster Cycle: • Preparedness • Developing/bolstering critical substrates • Response • Activating and implementing the plan • Recovery • Restoring normalcy • Planning • Recognizing risks and vulnerabilities

  11. Planning and Preparedness: • Essential: PPPPPPPP • Failing to plan is planning to fail…. • Be Aware of Possible Events • For community and hospital • “All hazards” approach makes sense • Plan for Most Probable Events • Planning more important than a plan • Also Plan for Rare but Catastrophic

  12. How to Prepare for a Pandemic? • Preparing for a new flu pandemic • Focus on previous modern pandemics • “Evidence based preparedness” • Highlighting some hot-button issues • Not all inclusive, just some things…. • All-hazards preparedness • More “bang for the buck”

  13. Charge: who? Command and Ctrl Communication Coordination Convergence Contamination Capacity and surge Cooperation Chaos/confusion CISD Chronic Problems: “10 C’s”

  14. Charge: who? Command and Ctrl Communication Coordination Convergence Contamination Capacity and surge Cooperation Chaos/confusion CISD Chronic Problems: “10 C’s”

  15. Reality of current situation • Many hospitals are not prepared • Preparedness is contrary to business • Hospitals are not just hospitals • Hospitals depend on other services • Hospitals can be dangerous places

  16. What is “Surge Capacity?” • Pre-planned process to ensure care • Must address routine operations, too • Needed for all services • Staff needed to provide care • Stuff needed to provide care • Structure • Space to provide care (hospital or OST3F) • System of management to direct resources

  17. Surge Issues: Past Lessons • Patient volumes • Geometric growth in volumes • Supply shortages • Run low on common items • Vaccine supply extension • Studies to “stretch” vaccine by dilution • Elective surgery cancellations • Elective admissions, surgeries curtailed

  18. Hospitals are Dependents MJA 185 #10 S71

  19. Surge Capacity • Trend has been away from capacity • Systems are already running all-out • Surge planning: not good business? • JIT stocking of supplies • Casualization of staff • Non-traditional approaches required

  20. Health care system is: Fragmented Competitive Disorganized Broke Private At capacity and shrinking How can we possibly surge? Surge: Doomsayers Say…

  21. Capacity and Surge: • Beds are key hospital “service” • Staffing to care for bed and its patient • What goes into providing beds? • More than just a room with a bed • How do we ensure enough beds? • Need to know how many we need • Need to know how to provide enough

  22. Staff: Personnel Issues • Personnel trends: just-in-time staff • Temporary/agency staffing • Part-time (casual) employees • Multiple gigs • Union Issues? • Work hour restrictions?

  23. Staff: Personnel Issues • Current planning assumptions • 40% absenteeism!!! • Range of estimates worldwide • What is the proof?

  24. Why 40% absenteeism? • Schools: hardest hit • 20-50% of students out • Some kids held out • “Prophylactically” • Leads to some closures • Primary to university • Football, etc cancelled • Teacher absenteeism • 4x typical as well

  25. Why 40% absenteeism? • General Industry in ‘57 and ‘68 • About 2-4x usual rate were out sick • No disruption in industrial productivity • Less margin for this now?

  26. Why 40% absenteeism? • Hospitals: squeeze from both ends • Up to 10x normal ILI-like cases • Harder hit than industry at large • 30-40% staff absent was “nuisance”

  27. Staff: Absenteeism Surveys • General Population: • Range reported 35-50% fits with past data • First Responders: • 80% if no vaccine or PPE • 38% if no protection for immediate family • Medical workers: • 26% to provide care; 10% to avoid exposure • 50% of hospital workers • 28% in one academic medical center • 46% of health department workers

  28. Staff: Past Flu Absenteeism • Health care worker-specific data: • Canada: (1981) 6% (3x baseline) • Canada: (2005) 16% • USA: (2004) 44%

  29. Staff: Vaccine vs. Absenteeism • Shorter duration of sick leave • Lower attack rates if immunized • Not proven “cost effective” • May offer other benefit: reassurance • All of this assumes folks will get shots!!!

  30. Staff: Mitigation & Absenteeism • School closures proposed to slow flu • Many years start with young kids first • Problems with child care • Models predict 30% HCW miss work • Complicates other staffing issues

  31. Stuff: Spending $ for Surge? • HRSA: 500 beds for 1M people • Assume 50% to ICU, 50% acute • 3 days of supplies • Assume oxygen beds, suction available • $5.5M for basics • No 3rd/4th generation antibiotics, etc.

  32. Stuff: the Cost of the ABCs • Ventilators for mass critical care • Focus of lots of planning and discussion • Major potential source of costs • Bare-bones $3K to $15K each • Major potential source of controversy • Who gets them: from SNS? in ICU? • Prior solutions: work on your grip!!! • BVM used in Denmark, after Katrina

  33. Stuff: Blowback of Outsourcing • Many health care supplies from Asia • Estimate: 80% of consumables for HC • Anybody think of a problem here? • “Asian flu” “Hong Kong flu” “China flu” • Competition: empty shelves • Even in the best of times

  34. Stuff: Business Pan-Flu Plans • Many businesses use Just-in-time • Low stocking levels • Problems reverberate up the system • Can we get food, drugs, oxygen, etc?

  35. Space: Alternate Site Surge • New concept in surge capacity • Several possible functions/benefits • Protect the main facility • Provide medical care and shelter • Have been used with some success • 1957 flu in NYC • Houston floods, Katrina evacuees

  36. Systems Issues: Triage • The worried well and walking wounded • Vastly outnumber those really sick • 9:1 during 9/11/2001 • 500:1 during anthrax! • Survey: 1/4 have no one to care for them • High-risk groups even worse • Problems of over-triage • Increased mortality in most critically ill/injured • Over-worked staff at higher risk Anes Clinics 25: 161-777

  37. Systems Issues: Ethics • Disasters Demand Changes • In systems of care • In familiar moral and ethical “codes” • Key Issues for the hospital • Providers: safety vs. responsibility • Triage: equitably giving unequal care • Ethical preparation: policies in place • Preparation ethic: an obligation?

  38. Systems Issues: Ethics • Other dilemmas • Safety • Concerns of providers vs. patient needs • Community mitigation • Quarantine? • Masks, social distancing, hygiene, etc. • International issues • Travel/borders/immigration? • Trade? • Sharing resources with other nations?

  39. Systems Issues: Legal • EMTALA • Altered standard of care? • When? • For whom? • Sanctions for work refusal by HCWs? • Already in place in several states • License revocation, fines, imprisonment! • Does ability equate with obligation? • Do social obligations require risk taking? • Can expectations be enforced?

  40. Systems issues: Communication • Controlling emotions • Outbreak vs. epidemic vs. pandemic • Bring the whole family • The infamous “two-fer” • Keeping kids home • High attack rates in schools • Rest, fluids, antipyretics: education • Huge predominance of outpatient cases

  41. Systems Issues: Recovery • Recovering issues: • What about those who refused to work? • Will patients trust the standard of care? • All plans should address recovery • Transparency may help retain trust • Pre-planning helps

  42. Key Points: • Pandemics Will Happen! • Planning is as important as the plan! • We are expected to be ready!

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