Pandemic Awareness/Preparation

Nurses COVID

Updated:   Published

It has been my own personal project to follow H5N1 for the last 3 years simply because it interests me. Attracted to this type of information like a magnet, I've been watching this relatively new influenza virus to see where it will go, how it will change itself, and possibly change our world. I have followed its country by country outbreaks, and watched for the important viral mutations such drug resistance or changes that allowed it to more specifically target mammals.

Keeping in mind at all times that we will be cleared impacted as HCW, as well as being members of our communities, and having families of our own to care for, I wanted to start the new year by opening a single focused pandemic thread that would also look at what we are doing nationally to prepare for a future pandemic. Is this the virus to spark the next pandemic? No one can answer that question. We can look back at the past to the last few pandemics, and in particular to the most devastating one in 1918, and extrapolate useful information about them, but we can not predict the future. We can only make comparisons with our situation now, and learn what worked to lessen morbidity and mortality in those past events. And, we can look at those other viruses, and compare them with what we are seeing now. For example, H5N1 is a Type A virus. We know that all pandemics are caused by Type A viruses. It is also an avian virus. The deadly 1918 virus, H1N1 was also an avian virus.

For this thread, as in the previous threads, I will be making use of news sources, scientific studies, govt bulletins such as the MMR, as well as flu forums and blogs devoted to this subject for my sources. Because press information, particularly the foreign press, is not always available for later access when I am looking back to check recent historical information, the use of these blogs and forums are important because archived information quoting the media and all other sources is always fully and easily available there with no worries about information disappearing or no longer being available. They also fully document their sources or I would not be using them.

With this link from Avian Flu Diary, a well researched source that I highly recommend, we can read the words of outgoing HHS Secretary Leavitt on our state of preparedness. Leavitt has done an admirable job during his tenure, but admits that there is much left to do.

http://afludiary.blogspot.com/2009/01/hhs-releases-6th-pandemic-planning.html

afludiary.blogspot.com said:

A scant 33 months ago, I sent my first message about a race that HHS had just begun. As I said then, it was a race against a fast-moving virulent virus with the potential to cause an influenza pandemic. Since then, we have mobilized experts and resources across the country and around the world. I now send you this final message, as I look back at the unprecedented progress we have made in energizing a national pandemic influenza preparedness movement in those 33 months.

Today, many people mistakenly think influenza pandemics are a thing of the past, but influenza has struck hard in the era of modern medicine – much harder than most people realize. And it will strike again. Pandemics are hard things to talk about. When one discusses them in advance, it sounds alarmist. After a pandemic starts, no matter how much preparation has been done, it will be inadequate.

Specializes in Too many to list.

The Egyptian toddler case conundrum

http://scienceblogs.com/effectmeasure/2009/04/the_egyptian_toddle_case_conun.php#more

The Reveres at Effect Measure commentary on the changing demographics in Egypt. What does it mean that bird flu in Egypt has begun to infect an entirely new group of people? It's too soon to say, and without more data, we are left with speculation. It does seem to be more transmissible, but is it? Or, as some suggest, are the adults also carrying the virus but showing no symptoms?

The current case fatality ratio of 62% is horrific, and if a virus with that kind of CFR became easily transmissible from person to person it would be beyond catastrophic -- apocalyptic might be a better description. It's not impossible. It isn't mandatory that infectious agents moderate their virulence to become more transmissible, although it frequently happens. But both smallpox and HIV are examples where it didn't happen, and it doesn't have to on theoretical grounds. So if this is one that does, so much the better.

We will mention again that there are a number of unexplained patterns in the H5N1 story. In China cases have been appearing for years in areas where there are no reports of infected poultry. Is that because vaccination has allowed birds to survive but still be infective? Could be. Maybe there are also asymptomatic adults there. Could be.

The Editors of Effect Measure are senior public health scientists and practitioners. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts "Revere" to recognize the public service of a professional forerunner better known for other things.

Specializes in Too many to list.

Authors aim to prepare people for disaster

http://www.mormontimes.com/mormon_living/health_lifestyle/?id=7188

This is a good preparedness article. I have always admired the Mormons for their commonsense approach to emergency preparedness. This makes so much sense in these hard economic times. None of us can know what the future has in store. Unpredictable events such as natural disasters, pandemics, and bioterrorism happen. Most Americans have no training in emergency preparedness. It may be helpful for some of to have someone talk us through the basics, and this what these women do.

Harkness and Probert also emphasize that disaster can be something as big as an earthquake or ice storm or as personal as losing a job.

Something like pandemic flu could isolate a family in their home for up to three months.

When disaster strikes is not the time to begin to make a plan, they say.

People need to be thinking ahead and doing what they can, even a little at a time, to prepare.

Probert recommends working on three things to start: a three-month food supply of the basics such as rice, beans, corn and wheat, enough water for everyone in the family for three months and a financial reserve.

(hat tip PFI/pixie)

Specializes in Psychiatry (PMHNP), Family (FNP).

Yes thank you IndigoGirl for doing such a nice job of conveying this information. Myself and another nurse where I work have been following this issue, and becoming more and more concerned. Its not a "sexy" or "media priority" issue but it sure will be when it hits. Without creating a panic I think our leaders should be advising us to make preparations. Its all very sobering. I will sure keep a close watch on this thread. Thanks again.

Specializes in Too many to list.

You are quite welcome to use any of this information if you find it helpful, Smitty.

Indigo Girl, thank you for your kind words regarding the ReadyMoms Alliance toolkits that are available.

We all need to be aware of the impact a potential pandemic will have on the lives of our children. A pandemic from the H5N1 virus is most lethal to the young. A similar pattern was last seen only in 1918.

Today, 'baseline' child death rates have fallen to a very low level. The number of children who would die from an unmitigated 1918-like pandemic would be more than all the children who usually die over 15-20 years.* --*Source: Venkayya, US Homeland Security Council, CDC Community Mitigation Stakeholders Meeting, Dec 06

The CDC estimates that school-aged children are twice as likely to become ill from pandemic flu than working age adults. (40% vs 20%)* ... *National Strategy for Pandemic Influenza Implementation Plan

The CDC Interim Community Mitigation Guidance recommends early school closure for up to 12 weeks in a pandemic if the case fatality ratio (CFR) is 1% or more.

H5N1 tops the list as potential pandemic candidate, because it kills more than 60% of those infected (75% for ages 10-19). The worst pandemic in modern history, in 1918, 'only' killed 2% of its victims. Experts warn that there is no guarantee that the current high lethality of H5N1 will diminish in a pandemic.

The best thing that every family can do is to begin preparing their households NOW. Waiting for news of a pandemic's start will be too late. Times are difficult for many, given our current financial climate, but utilizing sales, coupons and small additional purchases during your shopping trip will all add up to help increase your pantry stock. Unfortunately the financial leisure that many have had the past several years may no longer be available, but that should NOT deter folks from starting to build their pantry stocks.

There are many things that can be done to begin home preparation and the 'Get Pandemic Ready' website is highly recommended to get this process started ( http://www.GetPandemicReady.org ).

This website was created by members of a grassroots, volunteer organization comprised of a group of concerned citizens committed to personal preparation and community resiliency as the foundation for getting though a pandemic. Members of the team used their own experiences and extensive research to gather practical and time-efficient advice to help families prepare for a pandemic. Topics include: Water, Food, Hygiene, Emergency Basics, Comfort, Staying Healthy, Safety, Special Concerns (the Elderly & Special Populations, College Students), Infants & Toddlers and Treating the Flu.

Specializes in Too many to list.

The Readymom information in the post above is highly recommended. With the current economic crisis, it may feel that you can do much to protect your family, but you really can. Remember, emergency supplies just make sense for any number of reasons not just as a pandemic prep.

Meanwhile back in Egypt, the local Ministry of Health has announced a critically ill case as of 15 April, and the victim is a woman, age 33. This is different from the mild cases that we have been seeing recently in Egypt. Perhaps she has a greater viral load if she is raising poultry or more ominously, there is a virulent strain of H5N1 also present in the area. The later is a probelm if we are truly seeing human to human transmission in Egypt as these viruses do pick up genetic material from each other. A virulent H5N1 becoming more easily transmissible is a big concern.

Egypt - Case Number 64

http://www.emro.who.int/index.asp

The Ministry of Health and Population of Egypt has reported a new confirmed human case of avian influenza on 15 April 2009. The new case is a 33-year-old female from the Kellin district of Kfr El Sheikh governorate. Her symptoms began on 7 April and she was hospitalized at Kfr El Sheikh Fever Hospital on 15 April. The patient received treatment with Tamiflu on the same day of hospitalization. Infection with H5N1 avian influenza was also confirmed by the Egyptian Central Public Health Laboratory on 15 April.

Investigations into the source of infection indicate a history of close contact with dead and sick poultry prior to becoming ill. She is in a very critical condition and is currently on an artificial ventilator.

Specializes in Too many to list.

Dr. David Fedson Interview Now Online

http://afludiary.blogspot.com/2009/04/dr-david-fedson-interview-now-online.html

Thanks to Avian Flu Diary for posting about an interesting interview by a doctor that has been suggesting some other treatment options other than antivirals which are likely to be in short supply if the next pandemic turns out to be a category 5 event such as the 1918 pandemic was. And, yes there will be another pandemic some time in our future as these are naturally occurring events every 30 to 50 years or so. How bad it will be is what is in question not the fact that it will occur.

The interview is archived.

I've written about Dr. Fedson a number of times over the past 3 years, and his call to study commonly available generic drugs for their potential use in a pandemic.

Radio Sandy Springs 1620 AM, is a low-powered Atlanta based talk radio station that simulcasts on the Internet. Radio shows are archived about 48 hours after they are broadcast, and are available to download or listen to.

An archive of recent Infectious Disease Hour shows may be accessed here.

The Dr. Fedson Interview is archived here, and can either be downloaded as an MP3 file, or listened to online.

Specializes in Too many to list.

Egypt - Another Critical Adult Case

http://www.flutrackers.com/forum/showpost.php?p=219540&postcount=28

What is wrong with this picture? This is the 65th case. The majority of the recently infected have only had mild symptoms of H5N1, and all have all been of toddler age. Now, we have these last two cases, both young women, and both are on ventilators. Why are they so sick, but the kids were not?

If translations are correct, the latest case lives within a few miles of the Cairo Airport.

http://www.flutrackers.com/forum/showpost.php?p=219540&postcount=28

A 25-year-old Egyptian woman has contracted the highly pathogenic bird flu virus after coming into contact with infected birds, the latest case in a growing spate of infections in Egypt, state media said on Friday.

The new infection brings to 65 the number of bird flu cases in humans in the most populous Arab country, which has been hit harder by bird flu than any other country outside Asia.

The woman, from El-Marg on Cairo's outskirts, was in a critical condition on a ventilator after falling ill with a fever on April 11. She was being treated with the antiviral drug Tamiflu, state news agency MENA reported.

Specializes in Too many to list.

Bangladesh

http://crofsblogs.typepad.com/h5n1/2009/04/bangladesh-b2b-outbreak-north-of-dhaka.html

They must not be using vaccinations in Bangladesh so that at least the death of the poultry acts as a warning that H5N1 is present in the area. Of course, this is devastating to those that depend on raising poultry as their source of livelihood unless they are compensated for the loss of the birds from the necessary culling that has to take place.

Some countries where H5N1 is now endemic such as Vietnam, and Egypt are very dependent on poultry as a cheap source of protein. They have been using vaccines to help keep the birds healthy. Of course, it is possible that the birds can still shed virus even if vaccinated. I am not sure why that is but it may possibly be due to the vaccines not being an exact match to the infecting strain of H5N1.

Over 2300 chickens were culled in a poultry farm here on Wednesday night following detection of bird flu.

Sources at the Upazila Veterinary Hospital said some chickens died at the poultry farm of Shahjahan Chowdhury in Rajashan Ghasmahal area in the last few days.

Specializes in Too many to list.

Report: Health Care Workers In Peril

http://afludiary.blogspot.com/2009/04/report-health-care-workers-in-peril.html

How does your workplace rate? Have you had any training at all to prepare staff for the possibility of an infectious disease outbreak? Do you know if your facility has Tamiflu available for staff? Mine does not. I asked the head pharmacist already.

No Tamiflu in stock...

In an effort to assess the extent of employer efforts in planning adequate safety and health measures for healthcare workers, a group of unions developed a "pandemic flu preparedness survey" to assess the level of preparedness on a facility basis.

The survey as distributed to union leaders across the country who represent healthcare workers in unionized facilities. One hundred four (104) facility surveys were collected by six unions in fourteen states.

The results of the survey indicate that health care facilities have made some progress in preparing for an influenza pandemic but much more needs to be done.

More than one third of the respondents believe their workplace is either not ready or only slightly ready to address the health and safety needs necessary to protect healthcare workers during a pandemic.

Given this lack of readiness, 43 percent of respondents believe that most or some of their fellow workers will stay home.

One-third of the facilities have yet to develop a written plan for responding to pandemic flu and only 54 percent of the facilities have identified healthcare workers who will be at some risk of occupational exposure to the pandemic flu virus.

Less than half the facilities surveyed (43 percent) have provided pandemic flu training to their workers, one of the fundamental elements of protecting workers from occupational hazards.

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Egypt - Update of Case #65

http://crofsblogs.typepad.com/h5n1/2009/04/egypt-more-on-the-latest-case.html

This unfortunate woman was 33 weeks pregnant, and has lost the baby.

Her family reported close contact with sick poultry. She experienced IUFD and was reported in very critical condition under artificial ventilation on April 17.

Egyptian Case #66 - Another Toddler

http://www.alertnet.org/thenews/newsdesk/LJ499966.htm

An 18-month old Egyptian girl has contracted the highly pathogenic bird flu virus after coming into contact with infected birds, the latest case in a growing spate of infections in Egypt, state media said on Sunday.

The new infection brings to 66 the number of bird flu cases in humans in the most populous Arab country, which has been hit harder by bird flu than any other country outside Asia.

The girl, from the north Egyptian province of Kafr el-Sheikh, was being treated with the antiviral drug Tamiflu, state news agency MENA reported, citing the health ministry.

http://www.recombinomics.com/News/04190902/H5N1_Cairo_Delays.html

Why would they wait so long to start Tamiflu treatment for the pregnant woman given the patient's symptoms?

If the patient admits to having poultry then the family's birds would be culled. Is that why she denied any poultry contact?

Looking at transmission dates of the different cases, Dr. Niman at Recombinomics is suggesting there are possibly many more cases than the official number, and that H5N1 is being very efficiently transmitted in Egypt.

We know that thousands of people have been hospitalized and tested negative by PCR in Egypt in the past few years but were they really negative? If treated with Tamiflu early enough after infection it is possible that they could test negative. Dr. Niman is suggesting that given the recent change in demographics in Egypt, it is time to look at this possibility by doing antibody testing of those cases and also testing sick toddlers that have had no contact with poultry as well.

The delay in treatment for this patient suggests she denied a poultry contact. The possibility is support by the delayed treatment of case #63 (6M), whose treatment was also delayed at the same hospital. Since she was confirmed and was in critical condition, the significance of the treatment should have been well known to the staff at Ain Shams Hospital, because case #63 was also treated there. These two cases appear to be a few miles apart (see updated map), raising concerns that this geographic cluster is signaling more efficient transmission of H5N1.

These concerns were increased by the confirmation of case #66 (2F) in Kafr El Sheik. This case followed a recent case (#64) in Kafr El Sheik in the same district (Kellin). Moreover the 8 day gap in disease onset dates raises concerns that these two cases are related, and case #64 infected case #66.

Specializes in Too many to list.

H5N1 False Negatives in Egypt?

http://www.recombinomics.com/News/04210901/H5N1_Egypt_WHO_Europe.html

Learning of PCR negative results in patients that we know are actually positive cases is not unprecedented as Dr. Niman is pointing out in this commentary. We have only to look at those cases that occurred in Pakistan in 2007 where the index case was a vet. He and three of his brothers were symptomatic. Only one of the 4 tested positive by PCR but the antibody tests indicated otherwise.

This season the cases have not just been focused in children, but have been in toddlers (11 of the 12 confirmed cases in children). This concentration in this narrow age group (1 ½ to 2 ½) raises additional concerns that the PCR testing of suspect cases in Egypt lacks sensitivity.

Such a lack of sensitivity was seen in the Paksitan cluster mentioned above. Although four brothers were symptomatic and had x-ray confirmed pneumonia, only one was PCR positive. One was not tested, but the other two were negative in spite of high H5 antibody levels (titers of 2560 and 320). Moreover, another brother who was asymptomatic and PCR negative also had an H5 titer of 320.

Thus, the Pakistan study demonstrated the limitations in PCR testing and raises concerns that many of the PCR negatives among the 99% of suspect hospitalized patients in Egypt are false negatives.

Therefore, antibody testing of these suspect cases, as well as toddlers that have symptoms but lack a poultry contact, are welcome and necessary and shoudl be addressed by the WHO investigation.

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