Influenza Pandemic Preparedness for Clinicians on the Frontline

Transcription

1 Influenza Pandemic Preparedness for Clinicians on the Frontline CAPT HA C. TANG, DO US Public Health Service Adjunct Associate Clinical Professor of Dartmouth Medical School, Community/Family Medicine Dept. Deputy Chief of Family Medicine Department at TCRHCC

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3 Co-Authors Reasol A. Chino, PharmD, BCACP Commander, US Public Health Service Assistant Director of Pharmacy Tuba City Regional Health Care Corp Sita Marie Shablack, PharmD LT, US Public Health Service Advance Practice Pharmacist I

4 Disclaimers Do not speak for the IHS or the USPHS No profits or financial gain

5 Objectives 1. History and lessons of past pandemics 2. How and when a pandemic can take place? 3. What a bad pandemic scenario looks like? 4. What frontline providers can do to blunt the impact of an influenza pandemic

6 21 st Century Epidemics/Pandemics SARS pandemic Re-emergence of H5N1 HPAI virus 2003 H1N1 influenza pandemic 2009 Ebola of 2014 in the West MERS in Middle East, to South Korea Zika virus in the Americas 2016

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10 Influenza Basics Human influenza A and B viruses cause seasonal epidemics Influenza B viruses are not divided into subtypes Influenza type C infections cause a mild respiratory illness

11 Influenza Basics The Influenza A virus subtypes are labeled according to an H (hemagglutinin) (H1 to H16) N (neuraminidase) (N1 to N9) Pandemic potential

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18 Updates for HPAI H7N9 Feb An HPAI H5N2 virus was detected in a wild duck in the United States. -H7N8 in Indiana farm -H7N3 avian flu in Mexican poultry - H5N2 in Taiwanese chickens -H5N1 affecting more farms in Nigeria.

19 Recent Pandemic History The "Spanish flu", , 500 millions infected The "Asian Flu", , 2 millions The "Hong Kong Flu", , 1 million H1N1 Pandemic of ,000 deaths

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23 A letter from a physician wrote on the 1918 pandemic It is only a matter of a few hours then until death comes [...]. It is horrible. We have been averaging about 100 deaths per day [...]. Pneumonia means in about all cases death [...]. We have lost an outrageous number of Nurses and doctors. It takes special trains to carry away the dead.

24 Recent Pandemic History in US H1N to 2010 over 12 months 60.8 million cases 274,304 hospitalizations 12,469 deaths Fatality rate at 0.02%

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28 H7N9 Avian Influenza? -Now on a fifth epidemic since March infections -30% to 40% fatality -Limited person-to-person spread of this virus have been identified in China, -having the greatest potential to cause a pandemic

29 Socioeconomic toll? -$4 trillions US consumers nonmortgage debt -$1.4 trillions student debt, 11% deliquent -$21.2 trillions national debt, another $7 trillions in 10 years. -Global debt at $247 trillions, exceeding 318%

30 Socioeconomic toll? -Societies and countries tend to recover from pandemics well -At individual levels-life long -Foster children-400,000

31 When can a pandemic occur? A new influenza virus subtype It must infect humans and cause illness It must spread easily and sustainably among humans

32 What are the pathways for an influenza pandemic?

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38 What frontline providers can do to blunt the impact of an influenza pandemic?

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40 Strategic National Stockpilesince $7 billions dollars Stockpiled products include: Antibiotics Chemical antidotes Antitoxins Vaccines Antiviral drugs Personal protective equipment Ventilators Other medical supplies

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47 A number of surveys have found that 16% 33% of HCWs may not report to work in the event of an influenza pandemic According to CDC on Emerging Diseases Article, Pandemic (H1N1) 2009 Risk for Frontline Health Care Workers, Volume 17, Number 6 June 2011

48 HHS Influenza Pandemic Plan 2017 Update 1. Surveillance, epidemiology,& lab activities 2. Community mitigation measures 3. Medical countermeasures; 4. Health care system preparedness and response activities

49 HHS Influenza Pandemic Plan 2017 Update 1. Communications and public outreach; 2. Scientific infrastructure and preparedness; 3. Domestic and international response policy, incident management, and global partnerships and capacity building.

50 What is the likely scenario of an Influenza Pandemic at ground zero?

51 Ventilator ICU Bed Capacity in US? Our nation has only 105,000 ventilators as of 2005, per NEJM

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56 Comparison of tools available to fight the next Influenza Pandemic

57 1918 Spanish Flu 21 st Century No antivirals No ventilators No antibiotics 1/3 of HCWs died? Majority young 20-40s yrs of age

58 1918 Spanish Flu 21 st Century No antivirals No ventilators No antibiotics 1/3 of HCWs died? No antivirals? No ventilators No antibiotics? 1/3 of HCWs will not show up for work

59 What are our defenses? -Infection Control -Pharmacotherapy -Vaccine -Social Distancing

60 Ground zero How do we manage overwhelming influx of patients?

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62 Inpatient setting -Central strategy: Triage early Must have separate housing units for confirmed and yet-to-be confirmed

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66 Call for Ethics Committee -To decide who meets the criteria for intubation and to be ventilated -If limited antivirals, prioritize -Triage those deemed to be Expectant Suspected vs confirmed influenza

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69 Why Influenza tend to be more prevalent in colder climates? -Transmission of infection was most efficient when the humidity was 20-35%; -It was blocked at 80% humidity.

70 Outpatient setting -Early spot and control dissemination -Hospital wide enforcement of proper use of masks -Consider humidity of 80% of all waiting areas

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72 Influenza Treatment -Tamiflu(oseltamivir) and Relenza(zanamivir) -Rapivab(Peramivir) in IV only -Supportive care -Aggressive bacterial treatment as needed

73 Vaccine Production Options -Egg based -Cell culture -Recombinant DNA

74 Public health response goals -Goal to contain outbreak as much and early possible -Massive vaccination campaign to follow -Prophylaxis with antivirals

75 Summary Influenza viruses are the most adaptable and deadly Our defenses are weaker than we hope for The key is how well hospitals handle sentinel cases Swift public health response