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Pandemic Influenza Exercise

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Ying Zhang

on 1 July 2014

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Transcript of Pandemic Influenza Exercise

photo credit Nasa / Goddard Space Flight Center / Reto Stöckli
Commonly seen respiratory infection
Viral infection
Common cold
Pathogens: influenza, parainfluenza, rhinovirus, Respiratory syncytial virus (RSV), etc.
Symptoms: runny nose, cough, low-grade fever, sore throat, and difficulty sleeping.

Commonly seen repiratory infection
Bacterial infection
Pneumonia, Bronchitis, etc.
Common pathogens: Streptococcus pneumoniae, Mycobacterium tuberculosis (Tuberclosis)
Uncommon pathogen: Bacillus anthracis (Anthrax)
Last longer (>10-14days)
Higher fever
Get worse over time
Persistent cough, difficult breathing, etc.
Seasonal flu vs. pandemic flu
What is seasonal flu?
Comes every year (Oct. through May)
Mix of old and new virus subtypes
Usually mild to moderate illness
Very young and very old are more susceptible
What is pandemic influenza
New influenza virus ( no immunity)
Severe disease ( especially among healthy young people)
Usually have animal origins
Pandemic Influenza Outbreaks
Infected 500 million
Killed 50 to 100 million (3 - 5% of the world's population)
Healthy young people were susceptible
Public Health Systems
Infectious Disease Surveillance
What is public health?
Source: http://www.ewashtenaw.org/government/departments/public_health/ph_portal/public-health-portal

WHO Definition for Public Health
To prevent disease
To promote health
To prolong life among the population as a whole
Focus on entire populations, not on individual patients or diseases.
Source: http://www.who.int/trade/glossary/story076/en/
How Infectious Disease Spread Out
source: http://www.nytimes.com/2011/02/08/health/research/08flu.html?_r=0
Infected people seeking medical attention
Physician-Laboratory-Health Department
Post-diagnostic data
Regular reporting
Not all hospitals/physicians participate
Novel Syndromic Surveillance Systems
Low cost
Not always reliable
False alarm
Surveillance systems that monitor over-the-counter flu medication sales
Flu hotline
Online search
source: http://www.nhsdirect.nhs.uk/CheckSymptoms
Work and school absenteeism
and more...
online symptoms checker


Principal cause of death: Bronchial Pneumonia
Contributory causes: Flu
Monitoring disease based on death certificates and vital statistics
Asymptomatic infection
Largest group among all the infection
Difficult to monitor
Samples collected for other purposes (e.g. blood drive, etc.)
Social Media
Extracting information from social media websites to monitor the trends of disease transmission.
Warning generated by surveillance systems
Characterization and assessment
Activation of emergency response
Improving public health emergency prepareness
Infectious Disease Outbreak
Disease onset
Novel disease
Old disease with new features
Affect different population
Changes in severity and transmissibility
Sudden increase in number
Unusual clinical characteristics
Epidemiological investigation
Contact tracing
How severe is the disease?
How it is transmitted ?
How easily does it spread?
Do we have immunity?
How to treat/prevent?
Epidemiological investigation
Contact tracing
Enhanced surveillance
Pharmaceutical intervention
vaccination and antibiotics
Non-pharmaceutical intervention
Qurantine and isolation
School closure
Social distancing
Risk communication and education
Lesson learnt
Pandemic Influenza Outbreak Simulation
March, 2013
March 16: Case D brought to the clinic by her husband
She is a nurse who had treated Case A
March 17: A teacher in the village who had helped care for Case C came to the clinic with respiratory symptoms (Case E)
March 20: Case E’s wife (Case F) developed severe pneumonia and died four days later
No evidence that she was in contact with poultry
March 25: The clinic’s doctor notifies the District Health Officer of the cases
National Ministry of Health notified immediately

March, 2013
March 8: two poultry farmers (cases A & B) were seen at a clinic in the rural Kalasin province of northeastern Thailand
March 11: a 48 year old farmer from the same village (case C) died of pneumonia
More than half of his flock of chickens and ducks had died in the previous week
March 14: Case A returns to the clinic with high-grade fever and pneumonia
Bacterial pneumonia secondary to influenza is suspected, and he is admitted and started on a course of antibiotics

End of March: Thai Actions
Report cases to WHO in accord with IHR
Thailand is capable of handling on its own.
“due to an abundance of caution”
In country
Intensive surveillance
Including mobile laboratories
Isolation and contact management
Surge planning

State Health Department
Centers for Disease Control and Prevention (CDC)
Provides funding
Provides guidance
Provides technical support
Lab capacity
Aggregate and analyze surveillance data at national level
Report surveillance data to CDC
Provides funding and allocate resources to local health departments
Disease surveillance and emergency response within the state
Update local health department with the latest infectious disease activities
Local Health Department
Report surveillance data to state health departments
Response to local outbreaks
Organizing local mass dispensing clinics
Sentinel Hospitals and Physicians
Report to state health department
Coorperate with local health department on outbreak investigation
Follow CDC guidance
Roles of federal, state and local health departments in infectious disease surveillance and outbreak response
Monday, April 12, 2013:
GU Situation Report
“GUH confirmed this morning that four Georgetown undergraduates who recently returned from a service trip over Easter Break in Thailand are ill with flu-like symptoms. All four live in undergraduate housing. Roommates of two of the students came down with upper respiratory symptoms yesterday evening. 12 other students on campus have sought care today at GUH or Student Health Services for severe respiratory illness. Samples have been sent to the DC DOH to determine if the A(H7N7) influenza strain circulating in Thailand is responsible.”

Friday, April 16, 2013:
8:00 am DC EOC Meeting
Georgetown University
Emergency repsonse team leader
VP for Student Affairs
Medstar Georgetown University Hospital
VP for Human Resources
Incidemt Management Team
DC Government
Public Health Director
State Epidemiologist
Public Safety
CDC Representative
DC EOC Meeting
Who’s in charge?
Who else should be included?
What is Georgetown's role as a school?
What is the hospital's role?
What steps should be taken to limit the disease?
Who should take them?
Who should be alerted?

Washington, DC
Friday, April 9, 2013:
WHO Videoconference
DC EOC Meeting
Enhanced surveillance
Contact tracing and management
Patient treatment and isolation
Social distancing
Community containment measures
Ensuring business continuity
Internal and external communication
National Level
World-wide Level
Social media
Public Health Emergency Response

Ying Zhang, Ph.D.
Colin Brody
Ett McAtee
Summer Medical Institute
Public Health Systems
What is public health?
Infectious disease surveillance
Public health emergency response
Clinical symptoms
Seasonal and pandemic influenza
Pandemic Influenza Outbreak Simulation
Mass Dispensing Exercise
Influenza Virus
RNA virus
8 Gene segments
Genetic mutation and reassortment
Antigenic drift and antigenic shift
HA and NA
1918 Spanish Flu
2009 H1N1 (Swine Flu) Outbreak
Virus first identified in California children
New York high school students had symptom onset after spring break in Mexico
Severity not as high as expected
Avian Influenza
Mass Dispensing Exercise
Greeting & Forms Distributor
Job Assignments
Emergency Plan
Things to remember
Good news
No evidence of efficient and sustained human-to-human transmission of H5N1 viruses
Bad news
H5N1-infected birds in Asia, Europe and Africa
Circulating widely among poultry in Asia
H5N1 infections of humans, although uncommon, have resulted in severe illness and high mortality
Emerging antiviral resistance
H5N1 viruses are continuing to evolve and have the potential for genetic reassortment to a highly virulent pandemic strain

First three cases identified in China on March 31, 2013
All cases had close contact with poultry
No evidence for human-to-human transmission
Hospitalized cases have high mortality rate ( about 40%)

Risk Communication:
What we know
What we don't know
What we have done and will be doing to find out those unknowns
How to protect yourself

District of Columbia Profile

•617,000 + Residents

•1.2 M Daytime Pop

•64 square miles

•Among the most dense urban populations in the U.S.

Most government employees & contractors working in D.C. live in MD, VA, DE, & PA.

Planning Assumptions

Aerosolized anthrax release (“CRI Incident”)
100% of residents require prophylactic or therapeutic medications
Head-of-Household dispensing is authorized
Time allocated to dispense medications is 48 hours

Greet recipients
Pass out forms
Provide calming instructions

Apply dispensing algorithm
Identify special needs

Doxy and/or
Anthrax Info
Medication Info

Small %
Allergic to both meds
Requires medical screening

Mission: Greet and direct household representatives; distribute screening forms; determine if household representatives require additional or special assistance
Area: Front/Entrance of Closed POD
Equipment: Pens, clipboards, Medication Screening Forms

Mission: Assist and direct persons through the Closed POD stations; identify and prevent flow bottlenecks, and ensure that lines are formed and move according to identified flow patterns
Area: Flow control points and along queuing lines

Mission: Review screening form ensuring it has been accurately and completely filled out; determines appropriate medication to be dispensed; mark form accordingly
Area: Tables in Screening Station
Equipment: Pens, clipboards, Medication Screening Form key, table, chair

Mission: Review screening form and dispense appropriate quantity and type(s) of medication; provide Information Packet to each Head of Household; mark the medication bottles with the first name of each recipient; collect Screening Form
Area: Tables in Dispensing Station
Equipment: Pens, clipboards, Medication Screening Form key, table, chair, medication

Medical Emergencies: “BLUE, BLUE, BLUE”
Exercise play will be stopped
Command Staff will assist and notify GERMS
Fire Evacuations: Follow Staff members out of the building to designated Assembly Area
Stay together

Stay calm at all times; speak in a calm voice
Remember that in a real situation, recipients would be unsure of what is happening and are relying on you to be calm and collected.
Your attitude will greatly affect the emotions of recipients!
Don’t “invent” answers
If you are asked a question you do not know the answer to, notify your Unit Lead for assistance
Keep things moving!
Please do not spend too much time on one recipient

Who is in charge when an outbreak happens?
Who are the important people to have at the table for a discussion?
How do you discuss these issues with the public?
How do you communicate with government when there is a local problem?

Questions should be directed to your Unit Lead
Practice like you play!
If you need to leave the site for any reason, notify your Unit lead BEFORE leaving you post.
Remember to properly hydrate yourself.
While working, you will be exposed to a large quantity of people. If you take a break and after your shift, wash your hands thoroughly.
The work you will be doing may cause some stress or other strong emotions. Please enjoy this experience and remember this exercise will help you be better prepared!
The Internet-based surveillance
Disease outbreak information collected from online media, "rumor", unofficial reporting, etc.
Does it work?
Enhanced Surveillance
What to look for? (Case definition)
Laboratory criteria
Clinical criteria
Influenza-like illness (ILI) : fever(>100F)+cough AND/OR sore throat
Epidemiological criteria
Travel history
How to find cases?
Daily request for reporting
Novel surveillance systems
Chief complaints at emergency room
School absenteeism

Pharmaceutical intervention
vaccination and antibiotics
Non-pharmaceutical intervention
Qurantine and isolation
School closure
Social distancing
Border control
Epidemiological Investigation of SARS Outbreak
Amoy Gardens in Hong Kong
>300 Infected
Virus spread through water pipes withing the same building (Block E) and via strong winds to other buildings
Things to consider
When medication and vaccines are not enough for everyone, who get the medication first? Doctors and nurses? Law enforcement officers? Political leaders?
Is quarantine easy?
People need food and supplies
Social distancing
Shall we shut down the metro to avoid gathering?
Risk Communication and Education
Fact sheet
Surveillance data
Do's and Don'ts
CDC category A bioterrorism agents/diseases
Spread easily
High mortality
Social disrruption
Anthrax (Bacillus anthracis)
Botulism (Clostridium botulinum toxin)
Plague (Yersinia pestis)
Smallpox (variola major)
Tularemia (Francisella tularensis)
Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo])
Surveillance Program against Bioterrorism
Monitoring people:
Syndromic surveillance
Monitoring the environment:
Biowatch progam
District of Columbia Profile

•617,000 + Residents

•1.2 M Daytime Pop

•64 square miles

•Among the most dense urban populations in the U.S.

Most government employees & contractors working in D.C. live in MD, VA, DE, & PA.

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