Case Study:
Pandemic Flu Scenario
January 11, 2007
Newark, NJ
This public health case study was developed by the Center for Public Health
Preparedness at the State University of New York at Albany. It has been
adapted by the New Jersey Preparedness Training Consortium and Rutgers
Nursing Center for Bioterrorism and Emerging Infectious Disease
Preparedness for use in training health care professionals under HRSA Grant
No. T01HP01407
RUTGERS COLLEGE OF NURSING
CENTER FOR PROFESSIONAL DEVELOPMENT
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New Jersey Preparedness Training Consortium
www.nj-ptc.org
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Ground Rules
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•
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Play yourself, but think outside your usual role
No wrong answers; try to find better ones
Avoid jargon and define acronyms
Assume the information is accurate even though
the scenario is hypothetical
• Facilitators are here to help you to think through
possible answers from multiple perspectives
• No one person is expert in all areas but we are
here to learn how different groups might interact
in an emergency setting
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Rutgers Nursing Center for Bioterrorism & Emerging
Infectious Diseases Preparedness Facilitators
• Mary L. Johansen MA, RN, Project Manager, The
Nursing Center for Bioterrorism and Emerging
Infectious Disease Preparedness
• Miriam Cohen, MS, RN, APN, Director of Disaster
Preparedness, New Jersey Primary Care Association
• Joy Spellman, MSN, RN, Director, Center for Public
Health Preparedness
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Objectives
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•
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Discuss the impact of an influenza pandemic on
your community, organization, partner
organizations, and professional activities
Identify problems and potential solutions that are
unique to your agency and community
Cite the identified problems and solutions with your
peers
State the proceeding and recommendations made
by the group in order to recognize the unique
perspective of public health in planning efforts.
State how critical thinking may be applied when
using simulation.
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It’s There!
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Background
June 2005
• For months the health
care and public health
community worldwide
has been watching and
studying the avian
influenza A/H5N1 virus
that has continued to
evolve in southeast Asia.
7
Background
• The recent outbreaks that began in
December 2004 have resulted in 59 cases
and 22 deaths in southeast Asia.
• To date no cases of human-to-human
transmission have been confirmed.
Source: WHO. June 16, 2005.
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What Makes a Pandemic?
• Novel virus sub-type must emerge to
which the general population has no or
little immunity
• New virus must be able to replicate in
humans and cause serious illness
• New virus must be transmissible from
human to human giving it the capability of
causing community-wide outbreaks
Weir E. CMAJ 2005;173:869-70.
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Avian Influenza:
The Virus
library.wur.nl/frontis/avian_influenza/
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Mortality Due to Influenza
The red line indicates observed deaths. The middle line or epidemic threshold is the upper
limit of expected deaths over an average of 5 years. The bottom line is the baseline death
rate. Excess morbidity & mortality is the difference between the two top lines. Note ↑ in
2002 and 2004. Deaths from flu & pneumonia usually range between 8.5-10.4%
http://www.medscape.com/viewarticle/517503_3
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Prophylaxis and Treatment
of Influenza
MMWR Morb Mort Wkly Ret. 2003:52(RR-8):1-36
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How Oseltamivir Works
Moscona A . NEJM 2005; 353:1363-73
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Lab Confirmed Cases of Human
Avian Flu as of February 21, 2006
Case-Fatality Ratio (92/170 ~54%)
14
Adapted from http://europa.eu.int/comm/health/ph_threats/com/Influenza/ai_current_en.htm. Accessed 5 March 2006
Suspicious Case
• In Hanoi, Vietnam a worrying case has come
to the attention of the Ministry of Health.
• A migrant worker (identified only as Mr. W.)
lies critically ill in an area health center with
an influenza-like illness.
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Investigation
• Two days ago Mr. W. fell ill on the job at the
Hotel Universal.
• According to the investigation, Mr. W. and
several others left their home village to return to
work in Hanoi, leaving sooner than planned
because 4 residents of his village had died.
• The symptoms of the deceased were similar to
what a companion suffered from after returning
from a 2-day trip to a regional market town.
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Alert
• The WHO Global Influenza Surveillance
Network reports the following on the situation
in Vietnam:
– Mr. W. has died, along with 8 other individuals
from his village who recently returned to work in
Hanoi hotels and private residences.
– Lab tests on collected samples from the victims
have isolated a new strain of avian influenza
A/H5N1.
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Alert
– Investigation concludes that human-to-human
transmission did occur in these cases.
– The new strain is highly pathogenic.
– The new strain can cause primary viral
pneumonia, unlike pneumonia in most
influenza patients caused by secondary
bacterial infection.
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Outbreak
• Initial investigation in the last 24 hours has
revealed 26 other suspected cases in area
homes and hospitals.
• Laboratory confirmation of the strain is
expected soon.
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Situation Update
• The number of cases in Vietnam has
grown to 62 confirmed by laboratory, 125
other under investigation, and 35 deaths.
• Neighboring countries of Laos, Thailand,
and Cambodia have reported confirmed
and suspect cases of influenza infection
by the new strain.
• Some cases were quickly traced back to
foreign travel and stays at the Hotel
Universal in Hanoi.
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Situation Update
• The ministries of health in China,
Indonesia and Canada report confirmed
cases of infection by the new strain.
– Some cases are in health care workers who
probably delivered care to infected travelers.
– Previously unsuspicious cases in patients are
being investigated retroactively.
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Casualty Report
July 2005
Vietnam
Laos
Thailand
Cambodia
Canada
Cases
62
12
17
4
6
Deaths
35
4
12
4
1
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Coming and Going (1)
International air travel:
• 2 million passengers per month
arrive on international carriers at
NYC airports
• 1,400 passengers per month arrive
directly from Canada at Albany
International Airport.
The New York State Thruway
serves 230 million vehicles per
year.
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Coming and Going (2)
Daily traffic at the New York Canadian border:
–
–
–
–
Train passengers: 200
Pedestrians: 1,800
Bus passengers: 4,655
Car passengers: 58,074
Source: Bureau of Transportation Statistics
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Discussion
• What questions from the public are likely?
• What should you do to prepare for outbreaks
in your local area?
• To prepare, what new relationships would you
need to form immediately?
• What resources can you call on to ease the
psychological strain on the emergency
response personnel?
• Flu response overwhelms routine health
department activities; should routine disease
surveillance and control cease?
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It’s Here!
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Local Outbreak
August 2005
• During the last week, 42 suspect cases of
infection with the novel pandemic strain
have been detected in New York State.
• Four suspect cases reside in Bergen
County, NJ.
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Source
• Investigation reveals that most
transmissions occurred at a Fresh Air Fund
summer camp session in Catskills.
• The session was attended by 240 campers
from around the region.
• Counselors and staff included local
residents as well as college students from
foreign summer abroad programs.
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Surge
• Local hospitals are seeing a surge of
patients in emergency departments.
• Political and health authorities are
bombarded with questions about what to
do.
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Vaccine Status
• There is no vaccine available.
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Casualty Report
August 2005
Global
U.S.
New York
Canada
Total Cases Total Deaths
to Date
to Date
2,730
1,150
750
231
420
106
670
150
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Discussion
• Who should be involved in developing
messages for the public?
• How might you use volunteer organizations to
help respond?
• What are the pros and cons of implementing
Unified Command for the NY-NJ regional
response?
• What resources will you run out of quickest?
• How will you meet the needs of people isolated
or quarantined at home?
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Breathing Room
Cases
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Impact
December 2005
• The pandemic has not been stopped and
the impact to date has been enormous…
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Casualty Report
December 2005
Global
U.S.
Total Cases to Total Deaths to
Date
Date
322 million
7.7 million
14.8 million
177,600
New York
950,000
11,400
New Jersey
350,000
4,500
1.6 million
19,680
Canada
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End of First Wave
Cases
• In the northeastern US
and most other parts
of the country, the
number of new
outbreaks has reduced
to a fraction of the rate
during the peak 3
months ago.
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Vaccine Arrives
• Reaction is mixed
– Fear of side effects
– Demand greater than supply
• Shortages occur at all levels:
International, national, state, local,
organization
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Overseas
• Outbreaks continue abroad.
• Poor countries on every continent are
experiencing local, savaging outbreaks in
remote regions and mega-cities alike.
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Prioritization
• Many advocate prioritizing the military for
vaccine, medications, equipment, and
medical personnel to maintain national
security.
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Psychosocial Impact
• After months of steady
outbreaks, few lives are
untouched by illness, death,
bereavement, and stress.
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Vigilance
• Public health authorities stress the need to
maintain infection control practices and
surveillance.
• Many believe they can relax a bit now that
the pandemic has lessened locally.
• History shows that another wave is likely.
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Political Tensions
• Some countries blame each other for not
preventing or stopping the pandemic.
• Poor countries make pleas for financial aid
and resources.
• Congressional scrutiny is constant.
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Discussion
• How do you address public concerns over flu
vaccine?
• What problems and solutions are likely to arise
with rapid vaccination efforts, given current POD
planning and experience?
• What private agencies do you need/want to help
with mass vaccination?
• Only half the expected vaccine arrives at your
area: how do you prioritize who receives it?
• What are security concerns at PODs?
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It’s Back!
Cases
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Second Wave
July 2006
• Illness and death rates have crept back up
again.
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On the Move
• Areas that normally serve only as vacation
homes for urban dwellers now see
unusually high population levels due to
urban “Flu Flight”.
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Overtime
• The staff shortage in healthcare facilities is
estimated to be an average of 40%, due to
both inability and unwillingness to work.
• Available staff see shifts extended and
vacation requests denied.
• Overtime pay and costs reach
unprecedented levels.
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Now Hiring
• Demand for able and willing healthcare
workers exceeds supply locally and
internationally.
• Employers that are able to are offering
enormous pay for temporary healthcare
workers, as during the SARS outbreak of
2003 when Canadian hospitals paid up to
$2,000 per day to physicians.
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Respiratory Intervention
• Assumptions:
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•
•
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Anticipate > 20,000 deaths in NJ
80% of decedents were intubated prior to death
1/3 of intubated patients will die
Deaths are calculated as distributed evenly over
10 mos.
• All 115 NJ hospitals have equal capacity
• Required ventilator capacity for flu only
• 4,800 per month
• 42 per month per hospital
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Surge Capacity
• Auxiliary hospitals increase in size and
number in temporary facilities and
structures.
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Surge Capacity Question
• What is the surge capacity for your
organization?
• Does it meet the required needs?
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Vaccination Campaign
• Immunization levels average 35%, with a
range between 10% and 60%.
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Casualty Report
July 2006
Global
U.S.
Total
Total
Cases to
Deaths to
Date
Date
644 million 15.5 million
355,200
New York
29.6
million
1.9 million
New Jersey
Canada
750,000
1.9 million
9,500
39,360
22,800
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Discussion
• What are the priorities for communication and
education?
• What determines maximum capacity to provide
care and services?
• Should specific hospitals be designated for
treating flu patients?
• What resources cost the most but do the least
general good? How do you allocate them?
• What are options to address mortuary capacity?
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Conclusion
• The rate of new infections with the
pandemic strain have fallen to levels
similar to non-pandemic strains, as have
survival rates.
• Vaccine production and delivery continue
to climb.
• Thorough evaluation of the response to
this pandemic is on-going.
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Casualty Report
December 2006
Global
U.S.
NY
NJ
Canada
Total Cases
967 million
44 million
2.9 million
1.5 million
4.9 million
Total Deaths
23.2 million
532,800
34,200
18,500
59,040
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Conclusion: Take-home
• Are we prepared to respond to pandemic
flu?
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•
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Individual
Local
Regional
National
International
• What steps are your agency taking to
prepare?
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Disclaimer
• The scenario is hypothetical. The
estimates of cases and deaths are NOT
official projections of morbidity and
mortality in the event of a flu pandemic.
They are provided for illustration purposes
only.
• Visit www.cdc.gov/flu/flusurge.htm to make
projections of the impact of flu in your
locale based on variable assumptions.
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Case Presentation
1
• 40 y/o W male presents for evaluation
complaining of non-bloody diarrhea of 48
hours duration
• Recent return from rural northeast (Kurdish
Autonomous Region) of Iraq after a 30 day
business trip now concerned because of travel
history
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Case Presentation
• Physical – 40 y/o well developed ♂ in mild
discomfort because of diarrhea and cough
• BP=110/70 P=90 R= 22 T=101.9
• HEENT- Mucus membranes dry, no conjunctival
injection
• Chest – Mild wheezes, intermittent tachycardia
up to 105 BPM
• Abd-  bowel sounds with diffuse mild
tenderness – no masses or point tenderness
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Case Presentation
• Musc/Skel – 4/5 - 5/5 strength normal
ROM
• Neuro – non-focal examination
• Labs sent, IV fluid started, X rays taken
• CBC –Moderate↓ wbc and platelets
• CXR- diffuse patchy interstitial infiltrate
• ABG-moderate hypoxia with resp alkalosis
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Case Presentation
• Sputum is non specific for pathogens
• Swab (+) for Influenza but nonspecific
• Patient vomits, aspirates and requires
intubation to control airway and breathing
• All hospital respirators are currently in use
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Case Presentation
2
• 65 y/o male, recently retired. History of
congestive heart failure presents in the
emergency room for evaluation
complaining of weakness, fever, cough,
chills, SOB and loose stool today.
• Recently returned from a trip last week to
Atlantic City with a senior group on a bus
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Case Presentation
• Physical – 65 y/o male in moderate discomfort
because of shortness of breath and cough
• BP=160/92 P=108 R= 30 T=101.9
• HEENT- Mucus membranes dry, no conjunctival
injection. LLE with 3+ edema.
• Chest – Moderate wheezes, new onset of atrial
fibrillation up to 128 BPM
• Abd-  bowel sounds with diffuse mild tenderness
– no masses or point tenderness
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Case Presentation
• Musc/Skel – 3/5 - 3/5 strength normal
ROM
• Neuro – non-focal examination
• Labs sent, IV fluid started, Lasix given IV,
X rays taken
• CBC –Moderate↓ wbc and platelets
• CXR- diffuse patchy interstitial infiltrate
• ABG-moderate hypoxia with resp alkalosis
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Case Presentation
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•
•
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Sputum is non specific for pathogens
Swab (+) for Influenza but nonspecific
Intake and Outake monitored.
Responds to diuretics and Tamiflu,
(oseltamivir)
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Acknowledgements
• References & Sources:
– WHO Global Influenza Preparedness Plan
– WHO Checklist for Global Influenza Pandemic
Preparedness Planning
– FEMA, HHS: Pandemic Tabletop, 1999.
• Exercise guidelines adapted from FEMA
• Case made available to NJPTC through NJ
Center for PH Preparedness in partnership
with SUNY Albany Center for PH
Preparedness
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Helpful Web Sites
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http://bioterrorism.rutgers.edu/
www.cdc.gov
www.who.in/en/
www.fao.org
www.oie.org
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