Update on Influenza and Pandemic Preparedness April 20, 2011

1. Update on Influenza and Pandemic PreparednessApril 20, 2011 Charles W. Mackett III, MD, MMM, FAAFP Senior Vice President and Chief Medical Officer Clinical Assoc Professor of Family Medicine UPMC

2. Educational Objectives • Review Latest Flu Vaccine Recommendations • Plan & Prepare Your Office For a Pandemic • Evaluate Partnering With Local & State Agencies • Discuss How to Register in the Medical Reserve Corps

3. Domestic birds Natural avian influenza cycle Pandemic disease cycle Shore birds Waterfowl Mammals (primarily swine) Humans Cycle of Avian Influenza viruses in animals & humans Direct bird to human transmission is also common

4. Pandemic Influenza Bird flu kills in Indonesia and picks up speed across Asia” •The China Post 10 January 2007 Licensed from Reuters

5. Pandemic Influenza Licensed from Reuters

6. Novel Influenza A/H1N1/2009 • April 15 - first infection confirmed CDC • April 26 - public health emergency declared • June 11 - World Health Organization raises pandemic alert to Phase 6 (i.e., pandemic in progress) • June 2010 - US public health emergency expires • August 2010 pandemic ended http://www.cdc.gov/h1n1flu/

7. Confirmed Human Cases – Dominant Strain Case Fatality Rate < 1% (WHO) Severe Pneumonia/Respiratory Failure Most virulent in children and young adults Most deaths under age 50 Rare in elderly Never disappeared Northern Hemisphere School clusters – CMU Current Situation H1N1

8. Children and Elderly Pregnant Women Respiratory Disease Cardiovascular Disease Diabetes Obesity Immunosuppression Minority Groups/Indigenous Populations Vulnerable Populations WHO August 2009

9. Universal Vaccination Age 6 Months and Older Annually When Vaccine is Limited, Focus: Ages 6 months – 4 years & over age 50 Chronic conditions including children on ASA (Reyes) Immunosuppression Pregnant women Nursing home residents Indigenous populations Health care workers & household contacts Vaccine Recommendations MMWR 2010

10. Pandemic Influenza “Don’t forget about H7, H9 or perhaps even H2” • Robert Webster, St. Jude’s Hosp 2007 No one anticipated A/H1N1/2009!

11. Highly Pathogenic Avian Influenza H5N1 “Bird Flu” “The most lethal influenza virus we have ever seen” • Robert Webster, St. Jude’s Hosp 2005

12. The First Known Highly Pathogenic Avian Influenza (HPAI) Panzootic Continues to smolder Confirmed Human Cases Case Fatality Rate ~ 60% (WHO) No Sustained Human To Human Transmission Indonesia Family Cluster Current Situation H5N1

13. Reported Infections in Birds and People:since 2003 UPMC Center for Biosecurity

14. Pandemic Influenza “The world will experience another human influenza pandemic sooner or later.” • Margaret Chan, Director WHO, September 9, 2007

15. “I’ve been through some terrible things in my life some of which actually happened!” - Mark Twain

16. Human H5N1 Licensed from Reuters

17. Pandemic Influenza Impact on Average U.S. Hospital • FluSurge model (CDC) • HHS planning assumptions • At peak (week 5 of 8) with 25% attack rate UPMC Center for Biosecurity

18. Morbidity And Mortality Within 12-16 Weeks US 50 Million 2 Million 500,000 Require Outpatient Care Hospitalizations Deaths PA 1.6 Million 37,800 9,100 UPMC Center for Biosecurity

19. Potential Health Impact • Demand Will Far Outstrip Capacity • Critical Shortage of Health Care Workers • RN’s, MA’s, EMS & Technicians • Critical Shortage of Supplies & Equipment • PPE, Meds, Vaccines, Oxygen & Ventilators • “Graceful Degradation of Services” (Joint Com) • Standard of Care to Sufficient Care • Shift From Chronic/Preventive to Acute Care • Defer Elective Procedures • Vulnerable Populations & “Chronic Critically ILL” UPMC Center for Biosecurity

20. Federal Role in Pandemic Response "Any community that fails to prepare with the idea that somehow, in the end, the federal government will be able to rescue them will be tragically wrong." • Michael Leavitt, U.S. Secretary of Health and Human Services at Pennsylvania Summit3/31/06

21. UPMC File Photo

23. UPMC Pandemic Plan

24. What Can You Do? Licensed from Reuters

25. Begin Planning Now • Review Available AAFP, CDC & HHS Guidelines & Checklists • “Checklist to Prepare Doctor’s Offices for Pandemic Influenza” • “Business Planning Checklist …” • CDC/ACIP “Recommended Immunization Schedule” • Adopt & Tailor to Your Practice • Flexibility is Critical

26. AAFP Resources & Links Clinical Care & Research Searching for clinical information?Check out American Family Physician, AAFP's Clinical Recommendations and Annual Clinical Focus.Looking for patient handouts?Visit AAFP's patient information Web site: familydoctor.org. Interested in primary care research?Visit AAFP's National Research Network and Annals ofFamily Medicine. Need disaster preparedness or pandemic flu resources?Check out AAFP's disaster preparedness and pandemic flu resources. www.aafp.org/online/en/home/clinical

27. Pandemic Flu: Physician Resources AAFP Resources Checklist to Prepare Doctor’s Offices for Pandemic Influenza -- Updated September 2010 Current Information Latest Information About Pandemic Flu -- From the World Health Organization (WHO) Checklists and Other Planning Materials Planning Checklist for Medical Offices and Clinics -- From the HHS Pandemic Information for Health Professionals -- From the CDC General Information Pandemic Influenza: State Public Health Agency Preparation and Response -- From the Association of State and Territorial Health Officials www.aafp.org/online/en/home/clinical

28. www.aafp.org/online/en/home/clinical

29. Epidemic Surveillance & Detection • Emerging Pathogen Case Definitions • Fever & Sore Throat, Cough or Dyspnea • GI & Neuro Sx • Travel History & Exposures • Monitor Media & Public Health Alerts • Appoint Single Point of Contact • Maintain High Index of Suspicion • Report Suspected Cases to Appropriate Authorities

30. Infection Control – Stop the Spread • Identification, Triage & Isolation • Cough Etiquette & Hand Hygiene • “Flu Bags” (mask, tissue, sanitizer) • Appropriate PPE & Masks for Staff • “Wash In & Wash Out” of Every Encounter • Appropriate Immunization & Treatment • Master Seasonal Flu & CAP • Use hospital disaster drills to prepare for mass casualties (AHRQ – SORT C)

31. Office Preparedness AAFP Booth

32. Office Preparedness AAFP Booth

33. Coordinate With Public Health • Isolation of Sick • Quarantine of Exposed Contacts • Social Distancing • Clinical Epidemiology • Monitor Homebound Patients • Don’t Forget Vulnerable Populations & “Chronically Critically ILL” (Katrina) • Understand Local Plans & Potential Roles of Family Physicians

34. Coordinate With Public Health • Florida Medical Reserve Corps • Information and registration • Visit www.servfl.com • Local County MRC websites

35. Surge Capacity • Reschedule or Postpone Routine Services • “Worried Well” (India 2006) • Revise Schedule Templates • Telephone Triage & “E” Communication • Alternate Care Sites • Community Points of Distribution (PODS) • Anti-virals (Oseltamivir) • Pandemic Vaccines if available

36. Communicate At Every Level • Language Appropriate Signage • Alert Patients to Report Symptoms • Individual Preparedness & Self-Care • Hotlines & Nurse Advice Lines • Open Lines of Communication • Patients -- Hospitals • Staff -- Business Associates • Colleagues -- Public Health • Designate Single Practice Spokesperson

37. Business Continuity Issues • Clear Expectations to Work • “All Hands” Needed to Stop the Epidemic • It’s What We Do Everyday (Flu, HIV, TB) • Protect & Support Staff • Infection Control & PPE • Non-punative Sick Leave Policies • Return to Work Guidelines & Screening • Recovered Staff • Volunteers

39. Business Continuity Issues • Cross Train to Maintain Essential Tasks • Engage Vendors & Alternative Suppliers • Coordinate With Payers, Banks & Creditors • Streamline billing processes • Ensure cash flow & payroll • Anticipate Behavioral Health Needs • Patients & Staff • Security

40. Cross Functional Training Mackett Baghdad File Photo

41. Recovery & Reconstitution • Prepare for Pandemic Waves • 1918-1920 Experience • Equipment & Supplies • Billing & Collections • Replace Sick, Disabled or Expired Staff • Behavioral Health Needs • Contact & Recall Deferred Patients • Clear Backlog of Postponed Services

42. Pandemic Influenza “Right now, a growing … challenge is overcoming … bird flu fatigue” •Henk Bekedam WHO January 29, 2007 Licensed from Reuters

43. What Will You Do? AP

44. Take Home Points • Begin Planning & Preparing Now • Master Seasonal Flu & CAP – Universal Vaccination Age 6 Months and Older • Infection Control – “Wash In & Wash Out” • Communicate At All Levels & Coordinate With Public Health • Personnel Management & Business Continuity Matter! • Adopt & Tailor Available AAFP, CDC & HHS Checklists

45. Resources • www.aafp.org/online/en/home/clinical/disaster prep/pandemicflu/mdresources • www.aafp.org/online/en/home/clinical immunizations • www.flu.gov • www.pandemicflu.gov/plan/healthcare/medical • Family Practice Management July/August 2009 • Chuck Mackett • charles.mackett@irmc.cc/772-563-4776

46. “Plans are useless but planning is indispensable” - Dwight David Eisenhower

47. Questions?