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2012/2013 Flu Update

Situational Update #1 Week of Nov 21 to Dec 1, 2012

Our coverage of influenza and influenza like illness begins this week. We'll continue weekly updates throughout the season season.

Influenza season starts about this time of year with a peak usually seen in early February. During an average flu season in the United States there are 35,000 to 45,000 deaths attributed to seasonal flu. Those most at risk of serious illness or death from seasonal influenza include people with severe medical conditions, impaired immune systems, or extremes of age young or old. Although vaccine remains the mainstay of flu prevention, proper use of personal protective equipment (PPE) and other non-pharmacological interventions can’t be ignored.

Review: Types of influenza
Influenza virus belongs to the category of diseases known as Orthomyxoviruses and is divided into three types(Type A, B,  and C). Type A influenza is the variety that causes us the most concern for mutation and has the largest possibility for creating a pandemic situation. Type A influenza is also the one we hear described by a combination of letters and numbers; H1N1, H5N1 for example. The “H”, more precisely HA, stands for hemagglutinin and “N” (NA) indicates neurominidase. Hemagglutinin and Neurominidase are proteins that allow the flu virus to enter a host cell, reproduce, and get out of the host cell. Some of the most promising medications used to fight influenza are Neurominidase inhibitors (NI). Tamiflu is a NI that has been widely used to treat flu and has recently come under concern as flu becomes resistant. There are 15 different types of HA and nine types of NA giving us a total of 135 potential combinations of type A influenza. The seasonal flu vaccine contains only two of those combinations. Hopefully they are the two most prevalent circulating strains.

Type B influenza is seen mostly in humans and although it's very common it is much less severe than Type A influenza. Type C influenza infects humans and swine and has a completely different pattern of surface proteins. Normally Type C presents with rare occurrences and has mild or no symptoms. In fact, by age 15 most people have antibodies against Type C influenza.

Mandate or not? There has been a lot of discussion on the topic of mandated flu vaccine with many opinions and views, but few conclusions. Many healthcare institutions have adopted a mixed program that requires vaccine or signing a declination form. There may be increased PPE use requirements for those who choose not to take the vaccine.  Unprecedented reports have begun to question the validity of seasonal flu vaccine. A CIDRAP report  suggested that vaccine actually had limited protection for young/middle age and only modest protection > 65. Tamiflu concerns have also been in the news with some accusing Roche Pharmaceuticals of withholding data relating to increased flu resistance with Tamiflu  use.

The media and public may not fully understand the terms used in biologic/pandemic situations. Simple working definitions can be easily explained to the public, increase understanding and decrease anxiety.
Isolation - People who are sick are kept away from those who are not.
Quarantine - People who are not sick, but may have been exposed, are kept apart from others until the incubation period passes.
Social Distancing - A term that can mean anything from not shaking hands or hugging, maintaining a distance of 3 to 6 feet away from others, up to staying home when you’re sick. Social distancing can be used to describe extreme recommendations that include school closure. “Snow day” is a term that is sometimes used to describe a period when everybody stays home to decrease the spread of disease.
Pandemic refers to a disease that has spread to a large number of people over a large (national or global) geographical area. Pandemic is not synonymous with large numbers of fatalities.

Non Pharmacological Interventions
NonPharm practices can save the day. If used properly they can be vital in curbing the spread of disease. The non pharmacological interventions of hand hygiene, respiratory etiquette, and appropriate social distancing should be used in any actual or suspected case of Influenza Like Illness (ILI). The key to personal protective equipment or PPE - is using it correctly. Routine practice makes perfect when it comes to PPE and may be more important than annual testing.

On the Web
Centers for Disease Control Flu CDC Flu
CDC weekly flu report
Center for Infectious Disease Researsh and Policy CIDRAP
American Journal of Infection Control AJIC
Google Flu Trends


Influenza Vaccine Overrated?

Study reignites vaccine, antiviral controversy

Debate to mandate the (flu) shot or not for healthcare workers in the United States continues as additional data suggests seasonal influenza vaccine may not be all its cracked up to be.

Canadian healthcare workers are getting two differing opinions on mandated flu vaccine according to a report published by Public Health Ontario/Canadian Medical Association. Some Canadian researches continue to endorse the mandated flu vaccine policy for healthcare workers citing an 86% effectiveness when the vaccine is well matched to circulating virus. Researchers also claim that flu vaccination of healthcare workers in long-term care facilities (LTCF) may decrease resident flu mortality by 5-20%. The Canadian report, published in CIDRAP, the Public Health Ontario editorial indicates that flu strains that may produce Guillian-Barre Syndrome (GBS) are avoided in vaccine production. Its not clear how, exactly, GBS causing strains of influenza are kept out of vaccine production.

In the United States many healthcare systems and some sates are mandating participation in a flu vaccination program, according to the Centers for Disease Control and Prevention (CDC). “Participation” may include mandated vaccine, vaccine or singing a declination form, or mandated to don a mask.

Adding to the vaccine mandate controversy is a report from the Center for Infectious Disease Research and Policy at the University of Minnesota. This report proposes that seasonal influenza vaccine offers little protection to otherwise healthy young and middle-age individuals. They also believe that the benefit may be even less for those greater than 65 years of age. The New York Times recently printed an editorial on this topic.

While the vaccine debate continues, use of the antiviral drug Tamiflu is drawing concern. You may recall that Tamiflu (oseltamivir), and a class of medications known as Neuraminidase (NA) inhibitors, has been used to treat influenza. These medications are also on the CDC list for the treatment of seasonal influenza. However, reports have suggested that influenza has become (or is becoming) resistant to Tamiflu. One report from the CDC (9 Jan 09) states early data from a limited number of states indicating that a high proportion of influenza A (H1N1) viruses are resistant to the influenza antiviral medication oseltamivir (Tamiflu®). An article in Medscape highlights Tamiflu concerns brought on by researchers in the British Medical Journal. If you'd like to read in scientific detail about Tamiflu resistance, check out this post from the Virology Blog.

What’s the answer?
We have to remember that season influenza A continues to change every year. Some years the vaccine is well matched to the circulating strain, while other years it may not be. Its important to have an understanding of the terminology, types and impact of influenza (see 3 things to know about seasonal flu MJ 11/10). You should also brush up on the non-pharmaceutical interventions of hand hygiene, respiratory etiquette, and (appropriate) social distancing.


Proposals fall short of correcting critical infrastructure problem

NY problems are valid but proposals miss the real issue

NY Gov. Cuomo and Sen. Schumer make proposals to harden NY critical infrastructure. Governor Cuomo is recommending that all gas stations be required to have a backup power source; solar panels or a gas generator. Similarly, Senator Schumer is pushing the Federal Communications Commission to require emergency power options for cellular communications networks.

Both proposals are important. Neither address the real problem of vulnerable infrastructure.

There is no doubt that the loss of power from any cause results in cascading infrastructure failures.  Communication and fuel availability are among those failures. Reports have indicated that 40% of gas stations in areas hardest hit by Hurricane Sandy had fuel in their tanks but couldn’t pump for lack of electricity. Its been estimated that 1 in 4 cell towers failed during the storm due to lack of power or inadequate backup systems.

But disruptions in the fuel supply and cellular communication are not the only problems created when the power goes out. People may not be able to pay for groceries at the local supermarket when power and communication to the “cash” registers is disrupted while others may not be able to breathe (for too long) at the local hospital if power to our ventilator is cut.
Ordering individual systems such as gas stations and cellular installations to establish auxiliary power corrects the problem for those pieces only and continues to leave other systems vulnerable.
At issue here is a failure to harden the bigger target: the Nations power grid as well as correcting individual facility preparedness shortfalls.

The recommendations by Gov. Cuomo and Sen. Schumer are not bad ideas, they just ignore the larger problem of a weak and vulnerable electrical infrastructure. If we’re going to consider mandating gas stations and cellular companies to install backup generators, why not mandate New York hospitals to improve their backup systems? After all, going without fuel and your phone is inconvenient, going without your ventilator is fatal. Ultimately, vulnerabilities that were either undetected or ignored in the backup power systems caused hospitals to be evacuated.
This also raises the issue of civilian businesses being considered part of critical infrastructure.
The U.S. power grid remains the most vulnerable of our critical systems. We’ve seen routine seasonal storms disrupt power for days, sometimes weeks. We’ve seen natural disasters disrupt services for months and Mother Nature is not the only threat to keeping the lights on.

Our Nations power grid is strikingly vulnerable to the threat of electromagnetic pulse (EMP), obsolescence and decay. Having discussion of power grids and blackouts is a difficult subject for many leaders and elected officials to talk about.

Focusing on cell service and gas stations is a lot like telling people how much drinking water they should have on hand. Its only half the story. You can have plenty of water to drink, but if you don't have enough to flush the toilet you’re going to have problems.

Why not harden the whole puzzle rather than little pieces of it?


Selling the Preparedness Mindset

A recent comment got my attention; it should get yours, too. 


Aaron Marks posted a comment in response to No surprises in Sandy's wake that will hit home for many in emergency management as we struggle to make a successful pitch for preparedness. Although his comment specific to business and commercial preparedness, I think the spirit of the post can be applied to the public/civilian.

Aaron Marks writes:

For most of the people who follow MJ you're preaching to the choir here. The million dollar question is how do we fix it? 

I spend most of my time these days trying to convince business owners to invest in preparedness - with extremely limited success. Most of the decision-makers and so-called leaders out there just don't want to acknowledge that there is an issue because once they acknowledge it there may be liability associated with failing to do something about it. How do we convince 'the massess' that preparedness is an INVESTMENT and not a cost?

Why is preparedness such a hard topic to sell?

We should put the word sell in parenthesis. We can be selling the idea of preparedness or selling a product or service related to preparedness, or both. In there may be the problem. We’re trying to convince people in the community, business owners, public officials, or civilians that a certain action needs to be taken when most of those we’re selling to haven’t ever experienced any kind of serious event. And they don’t think they ever will. Many individuals and business owners have used phrases like “that’s what I have insurance for” when rationalizing their lack of preparedness.

What we’re “selling” is the preparedness mindset.

Persuading anyone to buy or do something they don’t think they need is an extraordinary uphill trek. After terrorist attacks and natural disasters woke us from the slumber of complacency, we’re eager to hit the snooze alarm and get back to business as usual. Or at least back to business of the new normal...whatever that may be.

The sad and unrelenting fact is that in the face terrorism, pandemics, and devastating natural disasters, many continue to believe that “its not going to happen to me.” In June, 2008, we wrote about this in the posting In search of preparedness in America. That post generated considerable discussion. As I wrote then “governments seem to have lacked the stamina to keep up with preparedness...” and I continue to believe that today. The response to and recovery from Hurricane Sandy continue to make my point here in 2012. You’d think that with Sandy fresh in our minds that preparedness would sell itself.

The liability of acknowledgment.

We also described an interesting, yet disturbing trend in October, 2010 (see Cassandra Paradox)  - We’ll call it the Theory of Successful Blame.
“Emergency planners, managers, and responders are responsible for actions taken (or not) before, during, and after disaster situations. While emergency planners, managers and responder should be held accountable for their performance during crisis or the performance of their planning or training preparedness, it seems that the need to have a scapegoat overpowers the reality that many of the disaster situations are fluid and may not evolve as predicted. Unreasonable expectations need to hold someone accountable when an unpredictable situation goes astray.”
The point is that acknowledged or not, someone is going to be held accountable. The preparedness liability exists and will remain on someones shoulders. A review of of the Hurricane Katrina/Tenent Health decision is a good reminder of this.

How do we convince the masses?

What we should be doing is informing and keeping it simple. Informing that preparedness is a cost effective in financial and life safety terms. We can provide information and rationale that may be helpful in bringing awareness to the forefront.

E. L. Quarantelli (University of Delaware Disaster Research Center) is my most cherished resource on emergency management teaching. In his paper More and Worse Disasters in the Future (1991); Quarantelli provides us with decent talking points, if not ammunition, to get people thinking about their need to embrace preparedness (click here for PDF).

For example, Quarantelli suggests that:
  • Natural disasters will increasingly generate technological disasters
  • Old kinds of natural disaster agents will simply have more hit and along some lines more vulnerable populations to impact
  • There are technological advances that add complexity to old threats
  • Many of the future threats or risks have high catastrophic potentials by way of the casualties or kinds of injuries they may generate
  • Some of the future disasters while occasioning relatively few casualties or physical damage will be very economically costly or socially disruptive
Perhaps the most poignant statement in his paper is this:
Better disaster planning can mitigate the impact of these future kinds of disaster but will not prevent their occurrence.
 On a more individual note, you might consider advocating a preparedness program that focuses on the home and the family. Doing as much as possible towards making individuals and family groups will go a long way in making communities as a whole more resilient in times of crisis.


Healthcare realities you can't ignore...anymore

Healthcare facilities: part domestic preparedness and part public safety.

Simply meeting building and fire codes do not equate to resiliency and checking off the Joint Commission preparedness requirements does not mean you're prepared.

Healthcare facilities will need to function before, during and after an event. The goal is to maintain operation as independently as possible for any foreseeable threat in your hazard vulnerability assessment. Those that can’t do that will need to evacuate or move their operations to another facility. Sheltering in place or evacuation are clearly realities each facility must face. They’re big decisions. Both options require substantial pre-planning and functionality between facilities.

Sheltering in place.

Deciding to remain in your facility during an event (sheltering in place) is not an easy choice. On the surface it may appear that staying put is a simple thing to do but, sheltering in place (making the decision not to evacuate ahead of a threat) comes with its own set of risks. Hopefully you have a robust 96-hour plan that you’ve trained on and tested. Hopefully it’ll see you through the situation. Even with solid planing, we have to has how long can you remain in your facility without outside support? Of course you have memorandums of understanding (MOU) with a variety of vendors as required by the Joint Commission. So, you're set. Right? The interesting thing about MOU's is that your vendor has an MOU with  all their clients, not just you. Will they be able to deliver their goods or services when demand is maxed out by all clients? Consider that infrastructure damage, such as damage to roads and bridges, will prevent shipments from making it to your supplier and further, prevent them from making delivery to you.

Part of sheltering in place is having a series of decision points or triggers that will tell you when its time to change tactics. Trigger events are situations that cause you reconsider your current position and may indicate the need for evacuation.

If you haven’t got a functional 96-hour plan or if your plans are questionable, you may want to consider evacuation ahead of a threat if possible.


Evacuation of a healthcare facility is a major event. There are risks to go along with the benefits. Before you give the order to begin the evacuation process you need to consider the following:
  • Will this be a full or partial evacuation?
  • What is the available capacity of receiving facilities? Can they absorb the number of patients we wish to send?
  • Have the receiving facilities damaged by the current event or are they in danger of being evacuated themselves?
  • What resources are available to move people and equipment?
  • What are the risks of going out into the environment?

Keep in mind that surge capacity may exist before an event, but not during or after. Evacuations must be done early or pre-event whenever possible. Ideally, your evacuation plans and triggers have been shared and tested with other facilities.


No surprises in Sandy's wake

Foreseeable issues plague response, recovery 

We're all focused on the aftermath of hurricane Sandy and the level of destruction she delivered. Once again the bullseye of this natural event is a major metropolitan coastal area. Some have referred to Sandy as the Katrina of the Northeast.

They may be right in more ways than one.

We see the devastation and the agonizingly slow road to recovery unfold with a familiar, yet eerie, similarity to other natural disasters. We were hopeful that the pre landfall actions ahead of Sandy were a setup for success. What we're seeing is foreseeable, almost expected, issues that plague the response and recovery as if planners have forgotten the major lessons of past events.

As I write this post some two-weeks after Sandy's landfall, hundreds of thousands are without electricity. Fuel supply is short and access to gas stations is limited, punctuated by long lines and short tempers. Some major hospitals remain closed, patients evacuated to already over crowded facilities in area less impacted by the storm. Even FEMA withdrew assets for a short time.

Patience is at a premium as the public struggles to accept the fact that there is no timeline for recovery. No one knows when the lights will come back on or when the toilets will flush again. Anger is begging to surge as high as the flood waters.

All this is happening in an area with arguably the most resources and experience dealing with disaster.

All of this has happened before and it will happen again. The power goes out for along time, food runs short, fuel is in short supply, and the recovery efforts falls short of our expectations. This is not to say that NYC or New Jersey were not prepared. Rather a series of beliefs and issues make it possible for a Katrina or Sandy to cause the same situation in your city and mine.

The over emphasis on terrorism has caused us to forget about the power of natural events. Despite the ridiculous amount of money spent on fantasy homeland security efforts we remain woefully unprepared to mobilize for or recover from natural disasters.

Our power grid is the most vulnerable piece of critical infrastructure in the United States. Decay and obsolescence alone are enough to fuel the concern that our power grid is not up to the challenge of day-to-day use, note to mention the impact of a outside event on local service. No power means no heating or cooling. No financial access. No ability to pump fuel or water. Prolonged power outage and failure of the power grid are issues few want to acknowledge.

The healthcare community continues to be shacked by standards that don't equate to patient safety in disaster situations. Lack of funding for preparedness results in a halfhearted effort and "check the box" mentality that simply meets a vague requirement for bureaucratic satisfaction. Similarly, the inability to move beyond the insanity of Optimism Bias keeps some healthcare preppers from acknowledging their vulnerability to natural disasters.

The public suffers from a similar complacency. Even after seeing less-than-encouraging examples of our national response to disasters and a new definition of disaster, the civilian population seems to hang onto the fallacy that someone will come to the rescue, put food in the pantry, and turn the lights back on.  


Vermont EMS Conference

Vermont EMS Conference, Burlington VT

I'd like to extend a special thanks to conference attendees and organizers, especially All Clear Emergency Management, for inviting me to present at the Vermont EMS Con!

I truly enjoy public speaking and presenting at emergency service conferences and in 2012 I've been invited to conferences from Alaska to Vermont and many places in between. Speaking at conferences and meeting other emergency management and EMS professionals always excites me. I often return home energized from meeting proactive people and with a head full of new ideas.  The sessions on Special Needs in Crisis and School Bus Rescue were very well attended with a considerable amount of audience participation. Just the way I like it.

Travel to the Vermont conference had an added, albeit challenging, twist...hurricane Sandy. When I left home in the afternoon of October 28 predictions for Sandy's landfall were being confirmed. I figured I'd bump into this category 1 storm at some point.

On the NYS Thruway Eastbound

It wasn't long before I was driving along side convoys of utility trucks with license plates from the Great Lakes area to the Gulf Coast.

The road conditions pictured at left are actually from a local weather system and not from Sandy...I'd meet up with her later.

Welcome to VT

The approach to Vermont. Leaving New York and entering Vermont is punctuated by crossing Lake Champlain via this massive bridge.

Note that, while overcast, the weather is nothing less than cooperative at this point. From here its another hour into Burlington. A six-hour drive from Rochester, NY.

Sums up my feeling toward air travel in general

After getting checked in and settled I took a recon walk to check out the conference area and rooms.

Along the way I found a pumpkin carving display in the hotel lobby. The carvings had a obvious EMS theme.

The Scare Care pumpkin...precisely summarizes my feelings on air travel.

A bit less inventive but obligatory Star of Life pumpkin.

As I said, an EMS theme. When I checked back the next morning there was something missing.

Take note of the topic listed just below mine. I was impressed with the number of emergency management/preparedness topics at this conference. Rory Putnam is the EMS Clinical coordinator at Northern Essex Community College. He hit a home run with his talk on EMS preparedness. Rory and I had a few minutes to talk during lunch. I appreciated his insights on EMS and disaster situations and hope to have him on Mitigation Journal podcast soon.

No laptop for me.  This was the second conference I worked entirely from my iPad and controlled with the iPhone. I use Keynote (Mac version of PPT) on my iPad and Keynote Remote for iPhone. Connected via Bluetooth I can see current slide, preview next slide and view speaker notes on the phone.

The iPad/iPhone-Keynote setup is simple to use and user-friendly at the podium or walking around the room. 

The Special Needs topics have been growing in popularity. This session focused on preparedness, including a how-to on conducting a hazard vulnerability assessment.

As with all my presentations, I customized the content with Vermont-specific statistics to add relevance to the message. 

A not-so-ominous to the South approaching the Vermont/NY state line at 5pm October 29, 2012. 

Welcome to NY...just ahead of Sandy. I did feel a sense of accomplishment knowing I'd filled my gas tank in Vermont and paid a buck-fifty less per gallon than I would in NY.

This is also the point in the trip when the weather started to change. My drive through the Southeastern Adirondacks was a zig-zag of downed trees and wind-driven rain. It was also darker than I've ever known it to be. No pictures...but made it home safe.

Thanks, again to the organizers of the VT EMS Con. I had a wonderful, albeit short, visit. See you next year.


Evacuation: Should I Stay or Should I Go?

Not an easy decision but its not a trick question

When to order an evacuation is no easy decision. It never has been. Its also not a trick question and you have plenty of time to study for the test.

Controversy surrounding evacuation of civilian populations and healthcare facilities has bubbled for many years without clear resolution. And for good reason - there is no "one size fits all" approach to the problem.

The hard taught lessons from Katrina, Joplin, and Tokyo showed up on another disaster test. The final grade isn't in, but its not looking good. In the aftermath of hurricane Sandy, as the public and public health struggle to regain a foot hold on normalcy, we're wondering why problems of power, evacuation, sheltering, and fuel are persisting.

Here's a review of evacuation considerations from Mitigation Journal edition #41 - Should I Stay or Should I Go? Points to consider when deciding to shelter in place or Evacuate - overviews issues for individuals, families, and healthcare facilities to consider when making this critical decision.

MJ Podcast #41published October, 2007*
*Note: original audio from 2007 and has not been edited. It may contain outdated material.