Brennan sept2806

Health System Preparedness: The Emergency Department and Beyond PJ Brennan, MD Chief Medical Officer University of Pennsylvania Health System

Reality Check • Current H5N1 virus initially seen 1997 • Significant mutations necessary for pandemic – PNAS 2006;103:12121-6

• Need to be prepared for all possibilities • Plan requirements – Broad-based – Flexible – Fluid

Influenza Virus Transmission • Respiratory route – Primarily by large droplets – Possibly small particle “short distance” aerosols

• Contact – Hand contact with secretions

Transmissibility of Influenza • Average number of persons infected by each case (R0) calculated in pandemic outbreaks – 1918 pandemic - ~1.8 to 2.7 – 1957 pandemic - ~1.7

• Average R0 similar to SARS (~3) but much less than measles (~12) and mumps (~8) • Explosive outbreaks are due to short generation time of 2.6 to 3.5 days

Public Health Goals of Pandemic Planning 1.

2.

3.

4.

Delay and flatten outbreak peak Reduce peak burden on healthcare system Reduce number of cases Buy time #1

No intervention

#2

Daily Cases

With interventions #3 Days since First Case

Potential Tools to Reduce Transmission • Vaccine:

– probably unavailable in first and second pandemic waves

• Antiviral treatment:

– may improve outcomes but only modest effect on transmission – availability uncertain – efficacy unproven

• Antiviral prophylaxis of contacts:

– may have greater effect on reducing transmission

• Social distancing & infection control:

– should reduce transmission, but strategy requires clarification

Estimates of Impact of an Influenza Pandemic Moderate (1957-like)

Severe (1918-like)

Illness

90 million (30%)

90 million (30%)

Outpatient medical care

45 million (50%)

45 million (50%)

Hospitalization

865,000

9, 900,000

ICU care

128,750

1,485,000

Mechanical ventilation

64,875

745,500

Deaths

209,000

1,903,000

Breaking the Cycle of Transmission

Population-based Containment Influenza

Treatment Isolation

Prophylaxis Symptomatic / Infectious Exposure Susceptible Quarantine / Isolation Social Distancing Liberal Leave School Closure Infection Control

Shunting Latent / Infectious Infection Control Social Distancing School Closure Targeted Social Distancing

Asymptomatic / Infectious

Value of combining strategies – Longini model 70

Source: German TC. PNAS (online) April 11, 2006

% of population

60 50 40 30 20 10 0

Clinical attack rate

Antiviral stockpile needed

Base case (Ro=1.9) Generic social distancing School closure School closure + generic social distancing 60% Case treatment + 60% household prophylaxis 60% Case treatment + 60% household prophylaxis + 60% social prophylaxis (60% TAP) 60% TAP + School closure + generic social distancing

Layered Interventions Close schools

Keep children home

Household quarantine

Social distancing

↓ cases ↑ HH & community transmission ↓ HH & community transmission ↑ relative importance of HH & workplace transmission ↓ cases ↑ relative importance of workplace & community ↓ cases

Evidence for Social Distancing, Especially School Closure • Children are the main introducers of influenza into households, more susceptible to influenza and more infectious than adults.

• School closure helpful in flu outbreak, Israel – Significant decreases in children’s diagnoses of respiratory infections (42%), visits to physicians (28%), emergency departments (28%), and medication purchases (35%).

• Influenza immunizaton of schoolchildren associated with lower illness rates in total population – Controlled trial, small towns in Michigan, 1968-69 – Immunization of children in Japan, 1962-87 • Lower rates of isolation of influenza and other respiratory viruses in Hong Kong in SARS – Many social distancing measures, public mask use Reference: WHO Writing Group. Emerg Inf Dis 2006;12:81-7

Combining strategies – Glass model: Targeted Social Distancing % of population

30 25 20 15 10 5 0

Clinical attack rate

Base case (Ro ~ 1.6) School closure alone School closure + targeted social distancing School closure + targeted social distancing School closure + targeted social distancing School closure + targeted social distancing

(10% compliance) (30% compliance) (50% compliance) (90% compliance)

1918 Weekly Excess Death Rate by City 0.018 0.016

Excess Death Rate

0.014 Philadelphia Boston Milwaukee Minneapolis Baltimore Pittsburgh St. Louis

0.012 0.01 0.008 0.006 0.004 0.002

9/ 14 /1 9/ 918 21 /1 9/ 918 28 /1 10 918 /5 / 10 191 8 /1 2/ 10 191 8 /1 9/ 10 191 8 /2 6/ 1 11 918 /2 /1 91 11 /9 8 / 11 191 8 /1 6/ 1 91 11 8 /2 3/ 1 91 11 8 /3 0/ 1 12 918 /7 / 12 191 8 /1 4/ 19 12 /2 18 1/ 12 191 8 /2 8/ 19 18

0

Date

Weekly mortality data provided by Marc Lipsitch (personal communication)

Liberty Loan Parade to Promote Sale of War Bonds: Philadelphia, September 28, 1918

/1 9/ 91 21 8 /1 9/ 91 28 8 /1 10 918 /5 10 /19 /1 18 2 10 /191 /1 9/ 8 10 19 /2 18 6/ 1 11 91 /2 8 /1 11 91 /9 8 / 11 191 /1 8 6/ 11 19 /2 18 3 11 /19 /3 18 0/ 1 12 91 /7 8 / 12 191 /1 8 4/ 1 12 9 /2 18 1 12 /19 /2 18 8/ 19 18

9/ 14

Deaths Rates / 100,000 Population (Annual Basis)

1918 Death Rates: Philadelphia v St. Louis

16000

14000

Philadelphia St. Louis

12000

10000

8000

6000

4000

2000

0

Date

Weekly mortality data provided by Marc Lipsitch (personal communication)

Philadelphia *Estimated attack rate before interventions:

14000

10.8%

12000 10000 8000 6000

Churches, schools, theaters, places of public amusement closed

4000 2000

*derived from mortality data using 2% CFR

18 /2 8/

12

/2 1/ 18

12

/1 4/ 18

8

12

7/ 1

12 /

/3 0/ 18

18

11

/2 3/

18

Date

11

/1 6/

11

9/ 1

8

8 11 /

2/ 1

11 /

/2 6/ 18

10

/1 9/ 18

18

10

/1 2/

8 10

5/ 1

8

10 /

8/ 1 9/ 2

1/ 1 9/ 2

4/ 1 9/ 1

8

0 8

Death Rate / 100,000 Population (Annual Basis)

Philadelphia

St. Louis *Estimated attack rate before interventions:

14000

2.2%

First death recorded

12000

Mayor closes “theaters, moving picture shows, schools, pool and billiard halls, Sunday schools, cabarets, lodges, societies, public funerals, open air meetings, dance halls and conventions until further notice�

Closing order withdrawn

10000 8000 6000 4000 2000

*derived from mortality data using 2% CFR

18 /2 8/

18 12

/2 1/

18 12

/1 4/

8 12

/7 /1

12

18 /3 0/

11

/2 3/

18

18

Date

11

/1 6/

8 11

/9 /1

8 11

/2 /1

18

11

/2 6/

18 10

10

/1 9/

18

8

/1 2/

10

/5 /1

10

28 /1

8 9/

21 /1 9/

14 /1 9/

8

0 8

Death Rate / 100,000 Population (Annual Basis)

St. Louis

Importance of Early Intervention *Scenarios

Total Attack Rate (%)

Deaths

No intervention

46.8

80,405

Intervention at 12% attack rate

27.7

47,511

Intervention at 8% attack rate

23.9

41,045

Intervention at 2% attack rate

9.7

15,782

Intervention at 1% attack rate

5.3

9,107

Intervention at 1% with Antiviral Rx of cases, Px of household contacts

2.9

4,889

*Longini model for Chicago pop 8.8M, NPI intervention TLC w 30% compliance HH-Q

UPHS Emergency Management Triggers • Stage 1: Increased human-to-human transmission abroad • Stage 2: Disease detected in US • Stage 3: Disease detected locally

UPHS General Concepts 1 • Broad-based, flexible and fluid outline • May not be able to predict cause – SARS, monkeypox, WNV, etc.

• Specific actions will respond to course, pace and characteristics of disease – Pandemic Command Committee • Baseline assessment completed for each entity – August, 2006

UPHS General Concepts 2 • Limit access to each entity – Two easily secured entry points recommended • General screening area for employees and visitors • Influenza Evaluation Center – Distinct from Emergency Department • Home Care Services will assist management of patients from ambulatory practices

Employee Health and Safety/Worker Retention • • •

Chemoprophylaxis as indicated Vaccine when available University will likely close when US disease first detected • Dormitories can be used to house essential employees and their families • Communication!

Planning Strategies • Surveillance • Stockpile necessary equipment, supplies and medication • Novel staffing patterns – “Work quarantine” for exposed but well employees • Identify essential employees – Strict “stay-at-home” criteria • Plans to limit mass gatherings – Close cafeteria – Cancel Grand Rounds, meetings, etc – Telecommute when possible • Security • Communication!

Tiered Distribution of Antivirals and Vaccines 1. HCWs with prolonged contact with high-risk patients â–ş Physicians, RN, NP, RT, etc.

2. HCWs with prolonged contact with moderate-risk patients 3. HCWs with intermittent contact with high-risk patients â–ş Environmental services, MSW, case managers, etc.

4. HCWs with intermittent contact with moderate-risk patients 5. HCWs with prolonged contact with low-risk patients 6. HCWs with intermittent contact with low-risk patients

**Should be reviewed by Ethics Committee

Required Supplies • Antiviral medication • Alcohol hand gels • Protective gowns • Gloves • Face shields and goggles • Surgical masks • N-95 respirators

• Disposable BP cuffs • Disposable stethoscopes • Pulse oximetry probes • Linens • Screening thermometers • Transport

Screening Criteria • Based upon disease activity • Disease overseas (sustained human-tohuman transmission) – Symptoms, fever AND travel to pandemic region

• Disease in US – Symptoms and fever

• Local disease (or widespread in US) – Just symptoms

Limiting Transmission • Screen all employees and visitors daily – Colored wrist bands for each day

• • • • • •

Hand hygiene Masks for all visitors Respiratory etiquette Social distancing Contact precautions Airborne vs. “Droplet Plus” precautions

Infection Control •Patients

•Surgical masks

•Employees w/o direct contact

•Surgical masks

•Employees w direct contact

•N-95 respirator •Contact and droplet precautions •Hand hygiene

•Employees performing high-risk procedures

•N-95 and eye protection •Contact and droplet precautions •Hand hygiene

Surge Management • • • •

Fill all existing “open” beds Clear all “pending” discharges Forced discharge rounds Identify isolation unit – Relocate patients – Rhoads Building at HUP • Double occupancy of all rooms • Cancel elective admissions and procedures • Utilize non-traditional space for patient care – PACU – Clinic exam rooms – PT gyms, conference rooms, etc.

Other Considerations • Altered standards of care possible – Ventilator use, for example • Medical, nursing and dental students – Penn Care @ Home • Hospital must continue to provide “routine” care – MI, emergency surgery, trauma, etc.

• Security critical • Supplies for ambulatory practices • Coordinate with CHOP • Coordinate with Philadelphia DOH

Other Issues • Alternate use of dorms – – –

Essential personnel +/- families Healthcare workers Work quarantine

• Screening of essential personnel – Utilize health system plan – Limited access points

• Security • Communication – Internal – External

• Transportation

Health System Preparedness: The Emergency Department and Beyond PJ Brennan, MD Chief Medical Officer University of Pennsylvania Health System