Community Challenge of Pandemic Influenza Michael P. Dailey, M.D., FACP North Fulton Regional Hospital Roswell, GA.

Community Challenge of Pandemic Influenza

Michael P. Dailey, M.D., FACP

North Fulton Regional Hospital

Roswell, GA

Pandemic Influenza

Bird Flu Strikes Florida

The Question

Why worry about pandemic influenza?

The Answer

Flu Terms

Seasonal flu – influenza like illness year to year Avian flu (AI) – low pathogenicity in birds is

common H5N1 – highly pathogenic AI, deadly to domestic

fowl and transmissible to humans Pandemic flu – virulent human flu that causes

global outbreak with little natural immunity

Diagnosis

During influenza season, influenza like illness with cough and fever can be presumed to be influenza

Monto et al Arch Int Med 2000;160:3243-3247

H5N1

Hong Kong 1997-cluster of human cases associated with poultry

Claas et al Lancet 1998;351:472

Southeast Asia 2003-outbreaks in 8 Asian countries

Ungchusak et al NEJM 2005;352:333

Indonesia 2005-human clustering

Kandun et al NEJM 2006;355:2186

H5N1

Turkey 2006 Great Britain 2007 As of February 6, 2007

Total human cases 272 Deaths 166 Mortality 61%

MAA Initiative 2006

John Harvey, M.D. Matt Gwynne, M.D. Radio Sandy Springs Interviews

September 11, 2006 – December 18, 2006 Archived www.radiosandysprings.com 7pm Monday MAA Pandemic Flu Report, January 24, 2007

Summary of Findings

Medical Care Groups Critical A

Patients with respiratory failure due to viral or bacterial pneumonia

Critical B Identical patients for whom no ventilator support is

available Urgent

Patients requiring hydration or IV antibiotics and anti-emetics who could be sent home

Basic Uncomplicated influenza needing advice and/or

antivirals, but neither critical nor urgent care

Summary of Findings

The central issue for pandemic healthcare is how to respond to the loss of our most critical asset, the hospital.

How do we evaluate care needs in such a circumstance?

Statistics and Comparisons

Year Population Deaths % Severity

Index

1860

Civil war

31,000,000 620,000 2 34

1918 100,000,000 750,000 3 52

1957 170,000,000 70,000 0.15 2.6

1968 200,000,000 35,000 0.058 1.0

Pan 1.0 300,000,000 900,000 1.0 17

Summary of Findings

Evaluation of Roswell/AlpharettaPopulation 150,000

Mortality 1%

Infected patients 45,000

Deaths 450

Summary of Findings

Evaluation of Roswell/AlpharettaDeaths 450Critical care pts. 450 x 2 = 900Potential hospitalized 450 (50%)

Ventilator needs 450 (over 3 mos.)Ventilators available 50Patients saved by critical care 25

Hydration and Influenza

Dehydration common due to poor fluid intake, fever and rapid mouth breathing

Hosker et al BMJ 1994; 308:701

Dehydration and GI dysfunctionVanNieuwenhoven et al Eur J App Phys 2000;83:578

Airway dehydration and asthmaMaloney et al Chest 2002;121:1806

Dehydration related abdominal painShah et al J Coll Physicians Surg Pak 2004;14:14

Dehydration and/or renal dysfunction occurs on 24 to 35% of hospital admissions for influenza

Summary of Findings

Evaluation of Roswell/AlpharettaUrgent care pts. = 1% of infected 450Mortality in urgent care 20%Potential urgent care save = 360

Save 360 with urgent care vs. 25 by critical care (i.e. > 10:1)

Summary and Conclusions

Fulton County plan is based on hospital being open – the reality is otherwise

The hospital will experience 30-50% staff deficiencies during pandemic

We will need a voluntary plan to provide urgent care at off campus sites

We will need a community committee to develop urgent care plans including MD, hospital, EMS, and city government input

Pandemic Urgent Care

Fluids – 1 liter of NS IV antibiotics

Ceftriaxone 2 Gm (Rocephin) Ertapenem 1 Gm (Invanz) if Pen allergic

Antiemetic Phenergan 12.5 mg

Allergy Kit Antihistamine Steroid Epipen

Pulse Oximetry

Problems

Where will my neighborhood get care?

How will they know where to go?

Who will give it to them?

Who will provide logistic support?

Vaccine

“Barricade vaccine” “Rampart vaccine”

ED Kilbourne Viral Immunol 2004;17:350

H5N1 Clade 1 H5N1 Clade 2 – 3 subclades

Cross protection against death in ferretsGovorkova et al JID 2006;194:159

Call to Action

We will need a community committee to develop urgent care plans including MD, hospital, EMS, and city government representation

We will need you to provide the care in your community that will make the most difference

It will not be in the hospital